Heritage Hills

Type of visit: Case Management - Incident

Licensing program analyst (LPA) Eryn Kane Arrived to the facility to conduct a Case Management visit. LPA was greeted by, identified herself, and explained the purpose of the visit to Executive Director Tanya Pontecorvo, who granted entry to the facility. Today's visit was in response to a written incident report that the Licensee self-submitted to the CCLD San Diego Regional Office on 9/1/2026. Per the incident report, the facility received an anonymous report on 8/31/26 of alleged physical and verbal abuse of several residents. Facility staff initiated an internal investigation and the Police Department, Long-Term Care Ombudsman, and Community Care Licensing were notified. Two staff members suspected of the alleged abuse were removed from the care schedule and staff training on abuse reporting was scheduled. During today’s visit, LPA performed a brief facility tour and welfare check of the residents involved. Pertinent records were also reviewed and collected. At this time, no deficiencies were cited, however Executive Director Pontecorvo was advised that additional follow up visits may be warranted. Exit interview conducted. Report and appeal rights reviewed and discussed with Executive Director whose signature below confirms receipt.the state’s words, verbatim · CDSS document, Sep 4, 2026

Allegation investigated: Lack of supervision, resulting in hospitalization

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director (ED) Tanya Pontecorvo. On 04/02/26 it was alleged, "Lack of supervision, resulting in hospitalization." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, outside sources, and records review. Regarding the allegation, "Lack of supervision, resulting in hospitalization", it was alleged that a resident collapsed while at the facility and was transported to the hospital. While at the hospital, the resident tested positive for fentanyl. (Continued on LIC9099C, Page 2) Unsubstantiated (Continued from LIC9099, Page 1) Staff interviews revealed that Resident 1 (R1) had collapsed at the facility, was showing a higher than normal temperature, and was sent out for that reason. Staff 1 (S1) stated that the resident didn't seem to be a baseline and had recently started to under eat. Staff 2 (S2) corroborated S1's interview and stated that R1 was not eating enough. S1 and S2 confirmed that another staff member was present when R1 had collapsed in the facility, caught by staff, and helped R1 safely to the ground to be checked by the onsite medical staff. Staff 3 (S3) stated that when R1's vitals were checked, R1 appeared to have a fever. All staff confirmed that the resident did not return to the facility after the hospital visit and was moved to another assisted living facility following the hospital stay. Staff unanimously stated that there were no fentanyl treatments given to any other residents during R1's stay at the facility. Outside source interviews revealed conflicting statements from the hospital staff. Outside Source 4 (OS4) reviewed the medication list for R1 and stated that one of the medications taken by R1 could provide a false positive. Outside Source 2 (OS2) stated that one of the charge nurses at the hospital confirmed it was a false positive for fentanyl. Outside Source 3 (OS3) stated that when R1 was at the hospital, they were at their baseline. During the interview with the LPA, OS3 was vehement that they did not believe that this was a false positive result and that R1 was drugged. Records review revealed the medication list for the resident contained a medication that could produce a false positive for fentanyl. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with the ED, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 08-AS-20260402090829

Allegation investigated: Staff does not ensure resident is bathed Staff does not ensure resident can open the door to her room

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings regarding the above complaint allegation(s). LPA introduced themselves and disclosed the purpose of the visit to Executive Director (ED) Tanya Pontecorvo. On 06/30/26 it was alleged, "Staff does not ensure resident is bathed," and "Staff does not ensure resident can open the door to her room." The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, outside sources, and LPA direct observations. Regarding the allegation, "Staff does not ensure resident is bathed," it was alleged that Resident 1 is not being bathed per physician's orders/plan of care. (Continued on LIC9099C, Page 2) Unsubstantiated (Continued from LIC9099, Page 1) Interviews with staff revealed that R1 is to be bathed twice a week. Interviews with Staff 2 (S2), S3, and Staff 4 (S4) all stated that R1 has been refusing bathing services (a personal right they are allowed to exercise). Staff told the LPA that when R1 refuses their bath, they try to employ techniques to encourage bathing including calling R1's family to encourage healthy behavior. S2 stated that R1 would refuse bathes but more recently has agreed to bathe more regularly without the need of encouragement from family. In an Interview with R1, it was revealed that facility staff offer bathing services to the resident. R1 stated that they've recently worked out a schedule to help them in accepting those services. This corroborates staff interviews. Records review revealed that the facility staff were tracking the bathing refusals and updating the care notes to include attempts and solutions when R1 would refuse initially. Regarding the allegation, "Staff does not ensure resident can open the door to her room." it was alleged that Resident 1 does not have access to their room due to the door being too heavy/too difficult to open. Interviews with Resident revealed that R1 is able to open and close the door to their room. R1 stated that the door was heavy however during the interview the LPA observed the resident opening and closing the door with mild difficulty. The LPA inquired if R1 required help from staff to open and close the door every time they needed to go in and out to which they responded, "No I don't need staff to help all the time. Every once in a while." LPA Observations revealed that R1 could open and close the door to their room with minimal difficulty. During the demonstration, R1 told the LPA that the door was heavy. LPA notes that the door is a fire safety door and has been cleared by the fire department to be in use in this facility. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegationa aee UNSUBSTANTIATED. An exit interview was conducted with ED, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 08-AS-20260630141608

Allegation investigated: Staff does not prevent facility from being malodorous

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings regarding the above complaint allegation(s). LPA introduced themselves and disclosed the purpose of the visit to Executive Directro (ED) Tanya Pontecorvo. On 06/30/26 it was alleged, "Staff does not prevent facility from being malodorous," The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff and LPA direct observations. Regarding the allegation, "Staff does not prevent facility from being malodorous," it was alleged that facility staff do not perform preventative and reactive measure to ensure cleanliness with specifications of this case to Resident 1's (R1) room. (Continued on LIC9099C, Page 2) Substantiated (Continued from LIC9099, Page 1) Staff interviews revealed that staff incontinence care (including disinfecting and odor removal) is procedural and adaptive based on the needs of the resident. Staff 1 (S1) stated that with regards to R1, the conjunction of R1 refusing to bathe with the incontinence care that needed to be provided was adding to the malodorous smell of the room. Staff 3 (S3) stated the incontinence care routine for residents including checking them every 2 hours as needed, removing linens and soiled clothes from the room, and disinfecting the room to ensure cleanliness. Staff demonstrated knowledge of the proper procedures with incontinence care. LPA Observations revealed that on the initial visit to open the complaint investigation, the room in which R1 resides was malodorous. The LPA observed the room to have a strong ammonia like smell and the LPA had difficulty staying in the room for extended periods of time. The LPA visited the same room that R1 was staying in on a subsequent visit one week later and the room was markedly improved. The smell was greatly reduced and the LPA could stay in the room for extended periods of time. Based on relevant interviews and observations the preponderance of evidence has been met that alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the ED.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 08-AS-20260630141608

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Jul 15, 2026

87625 Managed Incontinence (b)... the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. Based on observation, interview, and recordreview, the licensee did not ensure that The facility was free of odors from intcontinence care, which posed a potential Health, Safety, and Personal rights risks to 1 of 78 persons in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: Licensee will ensure room of resident is clear of odors by 07/20/26. A representative of CCLD Offices will conduct a facility visit to ensure POC is cleared.

Allegation investigated: Neglect/Lack of supervision resulting in sexual abuse Staff did not maintain comfortable temperatures for resident Staff did not follow resident’s care plan Staff did not dispose of waste in a proper manner

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Mike McCoy. On 08/12/2025 it was alleged that "Neglect/Lack of supervision resulting sexual abuse." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff and records review. Regarding the allegation, "Neglect/Lack of supervision resulting sexual abuse," it was alleged that a resident sexually abused another resident in a common area due to lack of supervision from care staff. (Continued on LIC9099C, Page 2) Unsubstantiated (Continued from LIC9099, Page 1) Interviews with staff confirmed that Resident 4 (R4) and Resident 5 (R5) have engaged in sexual relations with consent with each other prior to the occurrence witnessed by the reporting party. S1 stated that both R4 and R5 display behaviors such as "inappropriate touching" and "disrobing in public" and that care staff are to redirect residents when they witness these behaviors occurring. S1 stated that the relationship is consensual as both R4 and R5 will seek each other out and that R4 and R5's families are aware of the behaviors. When R4 and R5 express these behaviors, staff follow the care plan (stated as redirection, and offering alternative activities) and report events to the families of the residents. Records Review was consistent with staff interviews. The physician's report for R4 lists diagnosis as follows: Dementia with behavioral disturbance, cognitive communication deficit, hemiplegia - affecting L nondominant side, and type 2 diabetes mellitus without complications. The service plan report subsection "Behavioral Management Service Plan" states that care staff will provide reorientation within the community and redirection as needed to manage behaviors and that staff will provide close supervision and frequent monitoring, especially in common areas and during interactions with other residents. The care notes for R4 dated from Jan 2025 to Nov 2025 consistently report when R4's condition of exhibiting behaviors as described above and staff's response. The notes include caregivers following the behavioral management service plan when R4 exhibits behaviors. The physician's report for R5 lists diagnosis as follows: Unspecified dementia unspecified severity, psychotic disturbance, mood disturbance, anxiety, and unspecified mood disorder. The service plan report subsection "Behavioral Management Service Plan" states that care staff will redirect resident promptly and respectfully when flirtatious or inappropriate behavior is observed. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. On 08/12/2025 it was alleged that "Staff did not maintain comfortable temperatures for resident" The Department’s investigation consisted of unannounced facility visits, interviews with facility staff and residents. (Continued on LIC9099C, Page 3) (Continued from LIC9099C, Page 2) Interviews with staff demonstrated knowledge of the rights of residents. Staff consistently reported room temperatures were to stay in compliance range around 74 degrees. S1 stated that when staff perform their checks on residents, they check the thermostat and shut/open windows depending on how the room feels and with consent from residents. Interviews with Residents corroborated staff interviews. In an interview with R3, they stated that the temperature changes in their room but it's not bad. R3 additionally reported that staff supplemented them with an oscillating fan to help regulate the temperature even more. LPA observations revealed temperatures of rooms of residents were within regulatory compliance. Based on interviews and direct LPA observations a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. On 08/12/2025 it was alleged that "Staff did not follow resident’s care plan." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, and records review. Regarding the allegation, "Staff did not follow resident's care plan", it was alleged that facility staff did not ensure that hospice bed rails were maintained on R1's hospice bed. Interviews with Staff consistently reported that any equipment brought in from hospice as a part of a resident's care plan must be maintained by the hospice provider and cannot be worked on by staff per hospice policy. S1 stated that as a result of an observation from R1's family about their bed rails, S1 placed a work order for R1's half bed rails to receive maintenance and encouraged the family of R1 to call hospice as well. According to staff, R1's family claimed the half bed rail placed against the wall on R1's hospital bed was loose/not attached. S3 stated they inspected the bed rail without adjusting it per hospice policy and that it was attached to the bed. LPA asked staff if R1 had the strength or capacity to push themselves and their bed away from the way to which staff replied that no, R1 was at no risk or strong enough to create that situation and fall between the wall and the bed. Additionally, S1 spoke to R1's family about their request for full bed rails on R1's hospice bed. S1 warned against that and the family's suggestion to put R1's wheelchair against the bed when R1 slept as those accommodations would be considered restraining R1. (Continued on LIC9099C, Page 4) (Continued from LIC9099C, Page 3) Records Review demonstrated that facility staff put in work orders for maintenance for R1's hospice equipment on 01/23/25, 01/28/25, 04/10/25, 08/23/25, and 09/05/25. Per the Hospice Inventory item pickup, dated 11/19/2025, R1 had the following equipment for use from 04/10/25 until R1 moved out of the facility on 11/19/25: two fall pads, hospital bed, over bed table, two half rails, mattress, recliner, 2 foot rests, high back wheelchair, and a pommel cushion. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. On 08/12/2025 it was alleged that "Staff did not dispose of waste in a proper manner" The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, and records review. Regarding the allegation, "Staff did not dispose of waste in a proper manner", it was alleged that facility staff do not clean the room on a regular basis which resulted in leftover fecal wipes in a resident's room. Interviews with staff demonstrated that staff are aware of the housekeeping schedules and proper sanitation requirements when providing care for residents. S1 stated, "twice a week that rooms are deep cleaned." With regards to continence care, fecal wipes are disposed in resident waste baskets and after each brief change, the plastic bag goes with caregivers to be delivered to the trash room. Interviews with Residents conflicted on the cleanliness within the facility. R2 stated that facility staff do not keep the facility clean but clarified that meant staff don't change the linens often enough. R3 stated that the facility was clean and stated their observations that staff are "always sweeping the hallways" or "cleaning up R3's room" when they provide care for them. Records review of housekeeping records demonstrated that care staff regularly cleaned R1's room during the time period of the complaint. (Continued on LIC9099C, Page 5) (Continued from LIC9099C, Page 4) LPA observed resident rooms as part of the investigation. Resident rooms did not have trash on the floor, the walls and windows were not dusty or dirty, and the linens appeared clean meaning they did not have noticeable crumbs, dirt, or stains. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Mike McCoy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 16, 2026 · control 08-AS-20250812104236

Allegation investigated: Resident was assaulted physically by a staff person, resulting in bruising

Licensing Program Analyst Amy Rodgers sent this report to the licensee at their known mailing address via USPS certified mail and via email to deliver the investigation findings for the above allegation. The department conducted a file review and interviewed staff and an Outside sources. On June 17, 2021, Community Care Licensing (CCL) received a report that Resident #1 was assaulted physically by a staff person, resulting in bruising. Staff reported that Resident #1 (R1) sometimes exhibited aggressive behaviors toward staff and other residents, including throwing objects and using profanity. All staff interviewed denied witnessing or having knowledge of any staff member physically assaulting R1. Unsubstantiated The outside advocacy agency confirmed having no knowledge or evidence to support the allegation, and records review revealed no documentation or evidence to substantiate the claim. The resident could not be interviewed due to passing away prior to the investigation. An outside healthcare agency noted occasional resident conflicts and described R1 as sometimes lonely with communication challenges and fluctuating orientation. The hospice nurse stated staff were attentive, responsive, and never observed treating residents disrespectfully. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur; therefore, the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Feb 21, 2026 · control 08-AS-20210617135703

Allegation investigated: Staff do not ensure that resident’s toileting needs are being met Staff do not respond to resident’s calls for assistance

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director (ED), Mike McCoy. On 12/09/2025 it was alleged that "Staff do not ensure that resident’s toileting needs are being met” The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "Staff do not ensure that resident’s toileting needs are being met," it was alleged that facility staff are not doing required incontinence checks and are not thoroughly performing care duties when checks are initiated. (Continued on LIC9099C, Page 2) Substantiated (Continued from LIC9099, Page 1) Interviews with staff revealed that staff are aware of the responsibilities of resident care regarding incontinence. Staff 1 (S1) stated that “care staff will perform the checks every two hours, we have rounds with residents in rooms.” Interviews with residents revealed that Resident 1 (R1) may not receive incontinent care that matches their needs. R1 stated that “Staff put a diaper on me because most of the time they don’t check on me. I can go to the bathroom by myself; I just can't transfer to my chair myself because I'm not strong enough.” R1 continued by stating they have experienced times when they were assisted by staff to go to use the toilet, but staff did not come back to assist R1 out of the bathroom when they used the signal system. Interviews with Outside Sources revealed parts of the incontinent care provided by staff that are not meeting the needs of R1. Outside Source 2 (OS2) told the LPA there were times when R1 was not cleaned properly after receiving care from the facility. Outside Source 3 (OS3) stated while taking care of R1’s incontinence needs, they noticed that care staff did not properly clean R1. OS3 told the LPA that there was a time when they were taking care of R1 that they discovered feces in R1's genitals due to the care the facility staff provided. Records review revealed that in a pre-placement appraisal dated May 2025, under the “Services Needed” section, it is indicated that R1 needs continence care. In a medical assessment dated October 2025, R1’s report under the “Overall Physical Health” section shows that R1 does not require care for Bowel or Bladder incontinence, however there is a note saying that they wear briefs for accidents; this corroborates resident interviews. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with ED Mike McCoy, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued on LIC9099C, Page 3) (Continued from LIC9099C, Page 2) On 12/09/2025 it was alleged that "Staff do not respond to resident’s calls for assistance” The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, " Staff do not respond to resident’s calls for assistance," it was alleged that facility staff are not answering Resident 1’s (R1) alerts through the facility signal system in a timely manner. Interviews with staff revealed that staff are aware that call times may vary based on the time of day including scheduled meals at the facility. Staff 1 (S1) stated that during meal times, it will take staff longer to answer the signal system. S1 confirmed that staff will communicate with each other to address needs based on priority and answer all residents’ signal alerts. Facility staff stated unanimously that signal calls should be answered within 10 and no more than 15 minutes. Interviews with residents revealed that when Resident 1 utilizes the facility’s signal system, it is not always answered in a timely manner. R1 stated in an interview with the LPA, “One time, I got left in the bathroom for 2 hours and I had my watch on so I was able to time it. Even when I pull on the signal chord, it doesn’t do any good." Interviews with Outside Sources revealed that facility staff are not consistent with answering signal alerts. Outside Source 2 (OS2) stated that during their visits with R1, they have used the call system with no answer from facility staff. Outside Source 3 (OS3) told the LPA that during their visit with R1 that facility staff did not show up for some time between 1 and 2 hours. This corroborates resident interviews. Records review revealed the facilities signal system record for R1 from September to December of 2025 was used 490 times and over half of the recorded durations of the signal lasted more than 15 minutes. According to the record, over 60 instances during the Sept-Dec period took staff over 1 hour to respond and/or resolve the alert. LPA Observations revealed that during the interview with R1, the LPA initiated the signal system in the facility to check response times. The LPA timed the staff and no one arrived after 20 minutes. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with ED Mike McCoy, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 08-AS-20251209161744

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 27, 2026

Basic Services 87464(f) Basic services... include: (1) Care and supervision as defined in Section 87101(c)(3) Health and Safety Code (c)"Care and supervision" means the facility assumes responsibility for... ongoing assistance with activities of daily living..." Based on observation, interview, and record review, the facility did not ensure that all resident signal alerts were answered in a timely manner, which posed a potential Health, Safety, and Personal rights risks to 1 of 76 persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2026

Plan of correction: Executive Director will implement inservice training to staff about signal system requirements and proper staff equipment care. Facility will send CCLD offices proof of training by 02/27/26

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Feb 27, 2026

Basic Services 87464(f) Basic services... include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications... Based on observation, interview, and record review, the facility did not ensure that all resident toileting needs were met, which posed a potential Health, Safety, and Personal rights risks to 1 of 76 persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2026

Plan of correction: Executive Director will implement incontinence care recording system to ensure staff are meeting resident needs. Facility will do inservice training and send CCLD offices proof of training by 02/27/26

Allegation investigated: Staff do not assist resident with feeding Staff leave resident in bed for an extended period of time Staff yell at resident

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director (ED), Mike McCoy. On 12/09/2025 it was alleged that " Staff do not assist resident with feeding." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "Staff do not assist resident with feeding", it was alleged that facility staff do not consistently make sure that Resident 1 (R1) has been provided a meal during meal times or in the instance that R1 chooses to eat in their room, that there is a staff member who assists R1 with their feeding as indicated in their physician’s report. (Continued on LIC9099C, Page 2) Unsubstantiated (Continued from LIC9099, Page 1) Interviews with staff revealed that during mealtimes, residents have the option of eating in the dining room, eating in their room, or refusing meals. Staff 1 (S1) and Staff 4 (S4) stated that residents who choose to eat in their room are not given food at the same time as residents in the dining hall, nor do they receive help from caregivers until the residents in the dining hall who require assistance are done eating. This can delay mealtimes for R1 who requests food in their room and require staff to assist with feeding. S4 stated that with regards to R1, they will check on them in their room during mealtimes, ask if they would like to eat with everyone in the dining room, and if not, they will offer a meal supplement/snack before R1’s dinner to help with the wait until they can finish assisting with dining room residents. Staff consistently stated that R1 will refuse meals and instead eat a meal supplement provided by their family. S4 told the LPA they believed it was possible that R1’s weight loss could be the result of R1’s eating habits at the facility (“R1 will only eat a couple of bites of their meals”) or a PRN medication’s side effects R1 takes daily. Additionally, S4 will ask R1 if they would prefer help with finger foods or sandwiches and assist based on R1’s preference. Interviews with residents revealed that there are times when food service is not prompt nor are staff present to assist if food is delivered to their room. R1 stated that staff are not consistent with bringing food on time and as a result R1 must rely on a supply of supplemental meals provided by their family to eat (this is not related to R1’s right to refuse meals which they will exercise on occasion). R1 told the LPA that there have been times when staff have delivered food to the room but will not stay to help feed them. This corroborates staff interviews. Interviews with outside sources revealed that Outside Source 2 (OS2) and Outside Source 3 (OS3) have observed R1’s experiences with the facility’s meal management. OS2 stated that they have called the facility in the past on an almost daily basis to check and confirm that R1 is fed at the beginning of mealtimes. OS2 and OS3 confirmed separately that there have been times they were with R1 at the facility and care staff did not provide notification or check on R1 for meal services. During those visits, OS2 has telephoned the staff from R1’s room asking if R1 was fed and reported that staff stated, “R1 refused food today.” OS3 told the LPA they were concerned about R1’s weight loss of 40 pounds during their time at the facility as a result of meal service inconsistencies. (Continued on LIC9099C, Page 3) (Continued from LIC9099C, Page 2) LPA observations of the facility revealed that when the LPA arrived to interview R1, R1 was receiving a meal service with assistance of a care staff member. Records review revealed that R1’s physician’s report from October 2025 states that R1 is able to feed themselves but requires assistance and supervision. R1’s physician’s reports dated from February and October of 2025 show that R1 lost 40 pounds which corroborates outside source interviews. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. On 12/09/2025 it was alleged that " Staff leave resident in bed for an extended period of time.” The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "Staff leave resident in bed for an extended period of time," it was alleged that facility staff do not check in on R1 frequently enough or offer activities and opportunities for Resident 1 (R1) to leave their room. Interviews with staff revealed that residents can participate in activities at the facility including walks around the neighborhood and planned events coordinated by the staff. Staff 2 (S2) stated that there are activities planned every day at the facility and that residents are welcomed and encouraged to join. Staff 4 (S4) stated that they try to encourage R1 to come out for meals and activities, but R1 typically refuses. In an interview with R1, it was stated to the LPA by R1 that they are dependent on staff to transfer to their chair. However, by R1’s own admission, they “stay in their room mostly by choice” and that staff “don't refuse to get [them] out of bed." This corroborates staff interviews. Records review revealed in physician’s reports that R1 is not bedridden and can ambulate around the facility with the use of a walker or cane. (Continued on LIC9099C, Page 4) (Continued from LIC9099C, Page 3) Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with ED Mike McCoy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. On 12/09/2025 it was alleged that "Staff yell at resident” The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "Staff yell at resident," it was alleged that facility staff do not treat Resident 1 (R1) with respect by yelling at them while receiving care at the facility. Interviews with staff revealed that staff unanimously agreed that they had not heard or witnessed other staff members yelling at residents. Staff 3 (S3) stated that the only time they’ve heard staff raise their voice to a resident was out of surprise and trying to redirect a resident’s behavior. Interviews with residents revealed that staff do not normally yell at residents. R1 stated "No, caregivers don't yell at me,” and that, “care staff are normally friendly and helpful." This corroborates staff interviews. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with ED Mike McCoy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 08-AS-20251209161744

Allegation investigated: Staff handled resdient in a rough manner

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Business Office Director Amanda Togia . On 05/28/2025 it was alleged that "staff handled resident in a rough manner." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "staff handled resident in a rough manner", it was alleged that facility staff were seen putting their hands on Resident 1 (R1) and yelling in their face which caused them emotional distress. (Continued on LIC9099C, Page 2) Unsubstantiated (Continued from LIC9099, Page 1 ) Interviews with staff demonstrated knowledge of the rights of residents. Staff consistently reported no knowledge of other staff members who were rough or caused injuries to residents. Staff consistently reported that they observe aggressive behaviors from residents and know that acting aggressive or rough in return will only exacerbate the problem. Interviews with Residents corroborated staff interviews that staff are not physically aggressive when caring for residents. Resident 2 (R2) stated that care staff are normally friendly and helpful in their daily life. Interviews with Outside Sources corroborated staff and resident interviews noting that staff are not physically aggressive with residents. Outside Source 2 (OS2) reaffirmed that they have not witnessed physical or rough mannerisms from staff when caring for residents, however they have noticed that staff can become exacerbated when communication between staff and residents breaks down during care services. LPA Observations of the staff interacting with residents revealed that staff are patient, helpful, and attentive when helping residents in their activities of daily living. Record review revealed that Resident 1 (R1) is legally blind, with a dementia diagnosis, and requires help in many of their activities of daily living. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Business Office Director Amanda Togia , to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 6, 2026 · control 08-AS-20250528084713

Allegation investigated: Staff left resident in facility vehicle

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director, Mike McCoy. On 11/18/2025 it was alleged that "staff left resident in facility vehicle." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "staff left resident in facility vehicle", it was alleged that facility staff drove Resident 1 (R1) on an outing away from the facility and when staff returned to the facility, they left R1 in the vehicle for an unknown amount of time without supervision (Continued on LIC9099-C, Page 2) Unsubstantiated (Continued from LIC9099, Page 1)the state’s words, verbatim · CDSS document, Dec 31, 2025 · control 08-AS-20251118135554

Allegation investigated: Staff caused injuries to resident.

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director (ED) Mike McCoy. On 10/27/2022 it was alleged that "staff caused injuries to resident." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "staff caused injuries to resident", it was alleged that facility staff forced a resident to go to bed early against their will and that staff injured a resident while they were showering. (Continued on LIC9099C, Page 2) Unsubstantiated (Continued from LIC9099, Page 1) Interviews with staff demonstrated knowledge of the rights of residents. Staff consistently reported no knowledge of other staff members who were rough or caused injuries to residents. Staff denied forcing residents to go to bed early. When asked about forcing residents to bed, S3 stated that it was counterproductive for the facility to force residents to bed as it increases a resident's likelihood to practice exit-seeking behaviors. S3 stated, "residents are happier when we provide choices and freedoms for them." Interviews with Residents corroborated staff interviews that caregivers do not tell residents to go to bed early or that they physically force residents to go to bed against their will. With reference to injuries from showering, in an interview with R1, they stated that even though they know they are not supposed to shower without help due to a history of falls, they attempted to shower by themselves before they were found by care staff and assisted. Records review confirmed that R1 has a history of Dementia, Major Depressive Disorder, and Anxiety Disorder. The care notes for R1 stated on 10/17/2022, (10 days prior to the initiated complaint), R1 "demanded to go to bed at 3pm." When staff came back to check on R1 an hour later, they found R1 on the floor. Staff did a safety check to ensure there were no injuries and helped them back into their bed. Additionally, R1's care plan corroborated that R1 required assistance with showering. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with ED Mike McCoy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 08-AS-20221027142705

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Mike McCoy Executive Director. The facility is approved to serve seventy eight (78) elderly residents. Of which sixty eight (68) may be non-ambulatory and ten (10) may be bedridden. Hospice waiver approved for twenty (20) residents. LPA and Mike McCoy Executive Director toured the interior and exterior of the facility and inspected resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Mike McCoy Executive Director, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. (Continued on LIC809-C) (Continued from LIC809) LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. Two (2) deficiencies was cited per California Code of Regulations, Title 22 (refer to the LIC809-D page). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Mike McCoy Executive Director to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 5, 2025

Allegation investigated: Neglect/Lack of Supervision resulting in serious bodily injury Staff hit a resident in care. Staff did not dispose of resident's diapers. Staff are not allowing a resident to receive phone calls.

Licensing Program Analyst (LPA) Sarah Hurt conducted a phone visit to deliver findings on the above allegations. Regarding the allegation Neglect/Lack of Supervision resulting in serious bodily injury records show the Resident 1 had multiple hospital admissions between May and June 2025 for agitation and aggressive behavior. On June 1, 2025, the resident was admitted and diagnosed with an age-indeterminate nasal fracture. The hospital documentation and Investigations Branch report did not identify how or when the injury occurred. Interviews with the facility’s Resident Service Director and the Durable Power of Attorney (DPOA) indicated that the resident had dementia, exhibited combative behavior, and frequently ran into objects. The DPOA confirmed no suspicion of staff abuse or neglect. Law enforcement conducted a call for service but did not take a report. Based on the evidence, there is no indication that staff neglect or lack of supervision caused the injury. Although the allegation may have occurred 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. Unsubstantiated Regarding the allegation staff hit a resident in care. There were no witnesses or documentation indicating that any staff physically harmed the resident. The facility reported the resident often exhibited aggressive behavior due to dementia, but staff utilized de-escalation methods and denied using force. The DPOA reported visiting frequently and expressed confidence in the care provided. Medical documentation showed no injury pattern consistent with assault. Law enforcement found no evidence of abuse when contacted. 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. Regarding the allegation staff did not dispose of residents’ diapers. Facility staff denied failing to dispose of diapers and stated that soiled briefs are immediately placed in designated waste bins. The DPOA reported that the facility maintained cleanliness and had no concerns about hygiene. No supporting documentation or witness statements corroborated the allegation. Due to the resident’s passing in July 2025, direct observation was not possible, and no evidence was located to support that neglect occurred. Although the allegation may have occurred 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. Regarding the allegation Staff are not allowing a resident to receive phone calls. Interviews were conducted with the Resident Service Director and the Durable Power of Attorney (DPOA). The facility Resident Service Director stated facility Medication technicians reported when Reporting Party called the facility it was mainly to yell at the medication technicians and Reporting Party would not even ask to speak to Resident 1. Resident Service Director stated facility staff never intentionally denied Resident 1 from speaking to Reporting Party. There was no evidence that staff isolated the resident. Although the allegation may have occurred 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. No deficiencies cited Per Title 22 Regulations. Exit interview conducted with and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 22, 2025 · control 08-AS-20250604102601

Allegation investigated: Lack of supervision resulted in resident consuming hazardous chemical.

On 9/29/2025, LPA Grace Donato conducted a telephone interview with the facility to deliver findings. LPA spoke with Excutive Director Mike McCoy and explained the purpose of the call. Regarding the allegation of Lack of supervision resulting in resident consuming hazardous chemical, Reporting party (RP) stated that a staff member mentioned a resident (R1) drank something from a Dr. Pepper bottle. When the staff member smelled it, it smelled like cleaning chemicals. During the course of the investigation, 7 staff members were interviewed. page 1 of 3 Substantiated S1 mentioned that from the information S1 had heard or obtained, someone had left out a Dr. Pepper bottle that had been taken from another resident R2. The bottle was left at the nurse’s station. The bottle was capped and closed, but no one checked to see exactly what the contents were. Another staff S2, stated staff had been advised in the past to throw away any open food or drinks that are left out since the memory care residents may be inclined to take them. S2 stated R1 had taken drinks from staff in the past. S3 stated that caregiving staff, in the past, have brought in cleaning agents from home such as Pine-Sol, Fabuloso, and Mr. Clean, diluted with water. The caregivers would bring in the cleaners to clean areas after residents “because of poop and pee.” S3 would bring in the cleaner Fabuloso but in its original bottle, and it always locked in her cleaning cart. S3 has never witnessed the staff bring the cleaning agents in bottles. S4 mentioned that the facility provides the cleaners to the housekeepers. There are four different types of cleaning agents that are dispersed by a machine which is in the rear area of the kitchen. The bottles are also provided by the facility. S4 also denies any care staff from the first floor bringing in their own cleaning agents from home. S5 saw a Dr. Pepper plastic bottle full of yellowish liquid inside. The bottle was capped and closed. It was full and located at the lower counter of the nurse’s station, near the computer. S5 thought the bottle contained apple juice that was taken from the juice dispenser in the kitchen. S5 did not open to smell the contents because he didn’t want to smell what he thought was someone else’s drink. S5 observed R2 begin to reach and touch the bottle and S5 told R2 not to. R2 complied and left, and S5 left the bottle where it was located. When the incident happened, S5 went to where R1 was and was being tended to in the living room, and he/she saw the same Dr. Pepper bottle on R1s walker, half full. S5 instructed (a staff member) to check the bottle which was capped. As the staff member took the bottle, he/she accidentally dropped the bottle, and the liquid began to “bubble.” The caregiver opened the bottle, and it smelled like soap. It was never determined who had initially put the bottle at the nurse’s station. All staff denied the bottle belonged to them. S5 denies any knowledge of staff bringing in their own cleaning agents or liquids from outside the facility. page 2 of 3 ***This is an amended report *** S6 was assisting monitoring residents in the TV living room, where residents were watching a movie. S6 was seated in the back of the room in the last row of seating. R1 was seated to the front of the room. A caregiver (doesn’t remember who) began to come into the room to assist and escort residents back to their rooms. The caregiver then approached R1 and stated R1 did not look good and was “gagging.” S6 observed the Dr. Pepper bottle on R1s walker. S6 picked it up to examine it and noticed a pinkish-orange transparent liquid inside, as if it was flavored water. S6 uncapped the bottle and it smelled like Pine-Sol or some other type of cleaning solution. S6 is not aware, or has never witnessed, any staff member bringing their own cleaning agents from home. Since the incident, staff were directed not to keep any personal items on the floor and to keep the nurse’s station clear. S7 explained that he/she went into the TV living room to begin assisting R1 back to the room. R1 appeared as if R1 was “drunk” and had clear saliva coming from his/her mouth. S7 lightly tapped and moved R1 to wake R1 up, and R1 began vomiting clear liquid. S6 responded, and it noticed there was a half full Dr. Pepper bottle at R1s walker. S7 denies knowing of any staff bringing their own cleaning agents to the facility in bottles. Based on records review, R1 needs to have safety checks every four hours, but on the physician’s report supervision is noted as 24 hours supervision/care management. Since there staff had been advised in the past to throw away any open food or drinks that are left out since the memory care residents may be inclined to take them but still left the bottle by the nurse’s station, the facility wasn’t able to supervise R1 for R1 not to take this bottle since there is an unknown liquid contained in it. At the time of the complaint inspection on 8/3/2022, licensee was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49. Based on observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D. Report is reviewed and a copy of the report and Appeal Rights is provided. page 3 of 3the state’s words, verbatim · CDSS document, Sep 29, 2025 · control 08-AS-20220725103724

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 1, 2025

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents... This was not met as evidenced by: Based on interviews and records review, R1 was able to ingest a chemical that was left unlocked/unsupervised by facility staff which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2025

Plan of correction: Licensee to provide an in-service training for staff regarding supervision of residents. Licensee to submit by POC Deadline.

Allegation investigated: Lack of supervision resulting in resident sustaining serious bodiily injuries from a physical altercation with another resident

On 9/29/2025, LPA Grace Donato conducted a telephone interview with the facility to deliver findings. LPA spoke with Executive Director Mike McCoy and explained the purpose of the call. Regarding the allegation of Lack of supervision resulting in resident sustaining serious bodily injuries from a physical altercation with another resident, Reporting Party (RP) reported an unwitnessed fight occurred in the facility. A staff checked on a resident (R1) at 5am and found R1 lying on the ground in blood. Staff members were interviewed during the course of the investigation. On 08/05/24, at about 0530 hours, S1 found R1 on the floor in R1s shared room also occupied by R2. S1 assessed injuries on R1 and called for assistance from S2 and after assessing the resident, S2 called 911, R1 had bleeding from the back of his/her head and face. page 1 of 2 Substantiated ***This is an amended report *** Responding Officer (RO), interviewed staff to determine how the incident occurred. S3 had informed RO that R2 had physically assaulted another resident in the past with a footrest from a wheelchair. S3 also added that when new residents move in the staff monitor them for 48 hours checking on them and making sure they are adjusting to their environment and staff conduct status checks every hour. During the investigation, RO was informed by S4 that he/she had just recently been hired on and was in training and onboarding and did not have the opportunity to review residents’ files or conduct follow-up assessments for residents like R2 regarding change of condition. It is unclear what action was taken after R2 had assaulted the previous resident R3. R2 continued to reside in the room without a roommate for over a month until R1 was assigned to that room. S4 informed RO that S4 did not check the diagnoses or care plans of the residents to see if the residents were compatible before moving them in together. It was reported by staff that R2 preferred to be alone and by himself/herself, R2 was not sociable with other residents and only engaged with the staff. R2 had panic attack disorder and anxiety, a mental health condition that should have been addressed to determine if R2 was suitable for the facility. S4 admitted to not reviewing service plans for residents and did not have the opportunity to address any change of conditions with the residents due to onboarding and trying to manage S4s responsibilities. S4 also mentioned that the facility was using outside agencies for caregivers and attempting to hire more staff. After the former RSD left some of the caregivers also left leaving them understaffed. Based on records review, R2 has had experiences of panic disorder which happens with sudden attacks of intense anxiety that occur without any specific trigger or situation. There is no record of reappraisal when the first incident happened with R3. Therefore, in the matter of Neglect/Lack of Care and Supervision resulting in R1 being assaulted by R2, the findings are substantiated. At the time of the complaint inspection on 8/8/2024, licensee was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49. Based on observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D. Report is reviewed and a copy of the report and Appeal Rights is provided.the state’s words, verbatim · CDSS document, Sep 29, 2025 · control 08-AS-20240806155419

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 1, 2025

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents... This was not met as evidenced by: Based on interviews and records review, R1 was assaulted by R2 due to staff lack of supervision and constant checks for R2 which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2025

Plan of correction: Licensee to provide an in-service training for staff regarding supervision of residents. Licensee to submit by POC Deadline.

Allegation investigated: Lack of staff supervision resulted in resident sustaining serious bodily injury from another resident.

LPMII RA, Donna Teutschel, conducted a telephone interview with Administrator, Mike McCoy. The investigation did not produce definitive supporting evidence or supporting witness statements to substantiate an allegation of neglect or lack of supervision on the part of Heritage Hills staff that caused or contributed to resident (R1) being assaulted by resident (R2) which resulted in injuries to R1. Although it was established that R2 had become more agitated and agressive he had not been physically violent with any other residents. Although the actual circumstances that led to the altercation wasn't witnessed, staff did observe R2 dragging R1 out of his room and dragging R1 down the hall, bleeding from her head area with a laceration to her forehead and a large hematoma. The staff interviewed acknowledged memory care resident R1 had “peeked” into the incorrect room occasionally but would appear to realize she was at the wrong room and then proceed down the hall. There were no witnesses to R2 striking or punching R1. The Oceanside Police Department responded to the incident and conducted an investigation. It was determined the case would not be pursued criminally and it could not be established the incident occurred due to staff neglect. The Department has determined the complaint finding to be Unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 22, 2025 · control 08-AS-20220714082610

Allegation investigated: Lack of staff supervision resulted in resident sustaining serious bodily injury from another resident.

LPMII RA, Donna Teutschel, conducted a telephone interview with Administrator, Mike McCoy. The investigation did not produce definitive supporting evidence or supporting witness statements to substantiate an allegation of neglect or lack of supervision on the part of Heritage Hills staff that caused or contributed to resident (R1) being assaulted by resident (R2) which resulted in injuries to R1. Although it was established that R2 had become more agitated and agressive he had not been physically violent with any other residents. Although the actual circumstances that led to the altercation wasn't witnessed, staff did observe R2 dragging R1 out of his room and dragging R1 down the hall, bleeding from her head area with a laceration to her forehead and a large hematoma. The staff interviewed acknowledged memory care resident R1 had “peeked” into the incorrect room occasionally but would appear to realize she was at the wrong room and then proceed down the hall. There were no witnesses to R2 striking or punching R1. The Oceanside Police Department responded to the incident and conducted an investigation. It was determined the case would not be pursued criminally and it could not be established the incident occurred due to staff neglect. The Department has determined the complaint finding to be Unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 22, 2025 · control 08-AS-20220714082610

Allegation investigated: Neglect/Lack of supervision resulted in laceration Resident bedrails in disrepair

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Mike McCoy. On January 21, 2025, it was alleged that neglect/lack of supervision resulted in laceration and residents bed rails were in disrepair. The Department’s investigation consisted of an unannounced facility visit, records review, and staff, resident, and outside source interviews. According to the allegation received, Resident #1 (R1) was being wheeled in their wheelchair to their bedroom by staff. When the resident got to their bedroom door they fell out of their wheelchair and sustained a head laceration. It was also alleged that the bed rails on R1’s bed were not secured. [Continued on LIC9099-C] Substantiated Review of R1’s medical assessment records dated March 2, 2023, revealed that R1 had a diagnosis of Alzheimer’s disease and dementia, was confused and disorientated, had limited ability to communicate, and could feed themself with set up assistance but required staff assistance for all other activities of daily living (ADLs). R1 was also non-ambulatory and had a secondary diagnosis of falls. Review of R1’s needs and services plan dated September 3, 2024, revealed that R1 required a wheelchair for ambulation and mobility. The Department attempted to interview R1 but R1 was unable to be used a reliable historian to aid in this investigation due to their baseline memory loss. Record review and interviews revealed that R1 was a high fall risk and had a history of witnessed and unwitnessed falls. Interviews with staff and record reviewed revealed that on January 18, 2025, R1 was being wheeled by Staff #1 (S1) to their bedroom from the common area. When R1 and S1 arrived at R1’s bedroom door, S1 bent over to open R1’s door using a key that was located around their neck. While doing so, R1 fell forward out of their wheelchair and hit their head on the ground. Interviews with staff and outside sources revealed that R1 had a history of bending over in their wheelchair. Interviews with staff and outside sources revealed the concern of R1 bending in their wheelchair could have been mitigated with a high back wheelchair. However, there are conflicting statements as to why the high back wheelchair was not obtained. On January 23, 2025, upon discharge from the hospital with hospice services, R1 obtained a high back wheelchair. Review of R1’s medical records revealed that R1 required nine sutures as a result of the fall. Record review revealed R1 suffered two unwitnessed falls prior to the fall on January 18, 2025. On February 1, 2023, and November 29, 2024, R1 was found on the floor by their bed. Records review of facility progress notes revealed that staff observed R1’s bed rails not in place after the fall on November 29, 2024. Interviews with staff and outside sources corroborated that R1’s bed rails were not secured. The bed rails were reported to be faulty. The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of evidence exists to support the allegations that neglect/lack of supervision resulted in laceration and residents bed rails were in disrepair. An immediate $500 civil penalty was assessed and is noted on the LIC421IM. Per Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Program Administrator of the Community Care Licensing Division. Two deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A plan of correction was jointly formulated and an exit interview was conducted with Executive McCoy, to whom a copy of this report, LIC 9099-C, LIC 9099-D, LIC421IM and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to. According to the allegations received, Resident #1 (R1) was admitted to the hospital for an unrelated injury when it was discovered that R1 was severely dehydrated and had a UTI. It was also alleged that the R1’s diagnosis of a UTI was due to incontinence care because the staff are not properly trained to provide said care. Review of R1’s medical assessment records dated March 2, 2023, revealed that R1 had a diagnosis of Alzheimer’s disease and dementia, was confused and disorientated, had limited ability to communicate, and could feed themself with set up assistance but required staff assistance for all other activities of daily living (ADLs). Review of R1’s needs and services plan dated September 3, 2024, revealed that R1 was dependent in toileting activities or unable to recognize need to use toilet. Review of R1’s medical records from their hospital visit from January 18, 2025, to January 23, 2025, revealed that R1’s diagnoses included dehydration and UTI. Review of R1’s progress notes revealed that on January 16, 2025, R1 had an episode of diarrhea and staff were instructed to keep the resident hydrated and to offer sports drinks. Interviews with staff revealed that during the time period of R1’s hospitalization, there was a stomach virus spreading throughout the facility to the residents with an unknown origin. The staff were instructed to document diarrhea, vomiting, and/or temperature. Interviews with staff unanimously corroborated that R1 was receiving at least five to six cups of water a day. Review of R1’s progress notes did not reveal any other incidents of R1 having an episode of diarrhea, thus records reviewed, and interviews did not reveal the source of R1’s dehydration. Review of R1’s medical records and interviews did not reveal the direct cause of R1’s UTI. Furthermore, review of facility’s staff records did not reveal that the staff are not trained to provide incontinence care. The Department attempted to interview residents in care, including R1, however, they were unable to be used as a reliable historian in this investigation due to their baseline memory loss. Interviews with outside sources, including medical professionals, did not support the allegations. Based on interviews and record review, the investigation did not yield a preponderance of evidence to conclude that neglect/lack of supervision resulted in severe dehydration, a Urinary Tract Infection (UTI) and that staff are not trained to provide incontinence care. Based on the foregoing, the allegation is unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director McCoy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. Records review of R1’s medical records revealed that R1 was transported to the hospital’s emergency department on January 18, 2025, following an unrelated injury. Review of R1’s emergency documentation revealed that R1 obtained a chest x-ray and was found to have no evidence of pneumonia. On December 30, 2024, LPA conducted an announced visit to the facility after the self-reported incident of R1 chewing on a pencil sharpener. One deficiency was cited per California Health and Safety Code during that visit. Based on records review and interviews, the allegations that neglect/lack of supervision resulted in pneumonia and there was lack of adequate staffing to meet resident needs is unfounded, meaning it was false, could not have happened, and/or is without a reasonable basis. The allegations have therefore been dismissed. An exit interview was conducted with Executive Director McCoy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 08-AS-20250121105214

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(4) · Plan of correction due date: Jun 6, 2025

87468.2 Additional Personal Rights ... (a)…residents… shall have... the following personal rights: (4) To care, supervision, and services that meet their... needs and are delivered by staff that are sufficient in...qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interviews and records review the licensee did not comply with the section above in that R1 was not provided care and supervision, which posed an immediate health, safety, and personal rights risk to one (1) out of sixty-four (64) residents in care.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: Licensee agrees to schedule an in-service training on the topics of care and supervision and send proof of scheduling to the Department by 6/6/2025. Licensee agrees to send sign-in sheet and training topics to the Department by 7/4/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jul 4, 2025

Personal Rights of Residents in All Facilities (a) Residents … shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interviews and records review the licensee did not comply with the section above in that one (1) out of (64) residents bedrails were in disrepair, which posed a potential health, safety, and personal rights risk.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: Licensee agrees to schedule an in-service training on the topic of personal rights and send sign-in sheet and training topics to the Department by POC date of 7/4/2025.

Allegation investigated: Neglect resulted in infections Resident room was unsanitary

Licensing Program Analyst (LPA) Iby Strong made an unannounced visit to open an investigation on the above-mentioned allegations. LPA met with Executive Director Michael McCoy and discussed the basic elements of the complaint. According to allegations, Resident 1’s (R1) care was neglected resulting in infections and R1’s room was unsanitary. During the investigation, LPA Strong collected facility records, conducted interviews and completed a facility visual inspection. According to the first allegation, R1 was moved out of the facility in February of 2025 after R1 sustained a urinary track infection and viral infection. Records collected revealed that R1 lived at the facility from October 28, 2024, until November 9, 2024, a total of nine days. Interviews with staff present established that R1 was moved out of the facility because responsible party was requesting a private room, and none was available. Unsubstantiated Records collected corroborated R1’s request for a private room. Outside source records revealed that as of October 31, 2024, R1 was receiving antibiotics for undisclosed medical diagnosis. Such records also revealed that R1 was admitted to hospital on November 11, 2024 for a viral infection and previous antibiotics were stopped. Based on this information, R1 was only at the facility for two days prior to being hospitalized. It was also alleged that in February of 2025, R1’s room had feces on the floor and was often messy. Records collected revealed that R1 lived at the facility from October 28, 2024, until November 9, 2024, a total of nine days. Records collected also showed R1 was not present at the facility as of November 6, 2024, when responsible party removed R1 and did not return. LPA facility observations made on today’s date did not reveal any information to prove facility is not sanitary or unclean. Based on interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director Michael McCoy, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were providedthe state’s words, verbatim · CDSS document, Apr 29, 2025 · control 08-AS-20250423154013

Allegation investigated: Lack of supervision resulting in resident sustaining multiple fractures from a physical altercation with another resident

Licensing Program Analysts (LPAs) Hannah Rodgers and Sabel Martinez conducted an unannounced subsequent visit to deliver findings regarding the above allegation. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Mike McCoy. The Department's investigation consisted of record review, interviews with facility staff, residents, and outside sources including medical professionals and family members. It was alleged that lack of supervision resulted in resident #1 (R1) sustaining multiple fractures from a physical altercation with resident #2 (R2). It was specifically reported that on June 10, 2024, R1 and R2 were in a physical altercation that resulted in R1 sustaining multiple rib fractures. [Continued on LIC9099-C] Substantiated The Department received video footage that corroborated the incident that occurred on, June 10, 2024, at 8:12 AM. The video footage revealed R1 and R2 in a physical altercation. Video footage depicted R2 punching R1 several times in the abdominal area and subsequently throwing R1 to the floor. Staff were summoned by a resident and assessed R1 and R2. A 911 call was initiated at 8:24 AM, and R1 was transported to a local hospital. Law enforcement was contacted and R2 was removed from the facility on a 5150-hold due to danger to others. The Department has investigated the allegation that Neglect/Lack of Supervision resulted in serious bodily injuries and has found that based upon record review, video recordings, and interviews, the licensee did not conduct a reappraisal of R2 to determine if the facility was appropriate placement after R2 exhibited multiple aggressive behaviors towards staff and residents. Therefore, the preponderance of the evidence standard has been met and the allegation is deemed substantiated. This deficiency is noted on the attached 9099-D and is cited in accordance with the California Code of Regulations, Title 22. An immediate $500 civil penalty was assessed, and a plan of correction was jointly formulated with Executive Director Mike McCoy. Per Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted and a copy of this report, LIC 421IM, LIC 811, along with Licensee/Appeal Rights (LIC 9058 03/22) were provided to Mike McCoy at the conclusion of the visit. Review of R1’s physicians report, dated July 19, 2023, revealed R1 has a diagnosis of dementia without aggressive behaviors. According to R1’s pre-appraisal, dated July 28, 2023, R1 uses a walker to ambulate through the facility. Review of R2’s physician’s report, dated May 14, 2024, revealed R2 had a diagnosis of Alzheimer’s Dementia, and had occasional aggressive behavior and confusion. Review of R2’s facility progress notes revealed multiple occurrences of aggressive behavior towards staff and residents after admission. Review of R2’s progress notes revealed on May 25, 2024, the day following their admission to the facility, R2 was in a physical altercation with Staff #5 (S5), resulting in R2 pushing staff up against the wall by the shoulders with full force. R2 then entered a resident’s room and began pushing the resident. Staff redirected R2 away from the resident. On May 28, 2024, R2 was observed going in and out of a resident’s room and pushing them out of their way. On June 3, 2024, while staff were assisting a resident, R2 entered R3’s room and pushed Staff #13 (S13). When S13 tried to redirect R2, R2 became agitated and attempted to tackle S13. On June 6, 2024, R2 entered R3’s room and became aggressive with R3, but Staff #8 (S8) was able to redirect R2. During the incident, R2 squeezed S8’s hands. On June 9, 2024, R2 displayed aggressive behavior by walking up to staff and hitting their fist into their hands. Record review revealed that after multiple occurrences of aggression displayed by R2, a reappraisal was not conducted to reassess R2’s needs or compatibility with other residents. Facility progress notes and medical records revealed that R2 was prescribed as needed medication for agitation and anxiety. Interview with Staff # 7 (S7) revealed a request was sent to R2’s physician for medication adjustments but denied receiving an updated prescription. Review of medical records revealed that the request was received on May 28, 2024, and medication adjustments were made by the physician, but delays occurred with an outside pharmacist. Interviews with 12 staff members were conducted (S1-S12). S1 – S3 reported that R1 and R2 were present in the Sea Breeze dining room when R2 assaulted R1. Interviews with S9 revealed that on June 8, 2024, R1 and R2 had previously been in a verbal altercation where R2 made verbal threats against R1, and staff had to separate them for their safety. Interviews with S4 and S5 corroborated the physical altercation that occurred on June 6, 2024, where R2 entered a resident's room and became aggressive with staff. The Department attempted to interview R1 and R2 but was unable to qualify them due to their cognitive state. [Continued on LIC9099-C]the state’s words, verbatim · CDSS document, Feb 24, 2025 · control 08-AS-20240725111316

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 25, 2025

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not ensure that R1 was provided care and supervision, which posed an immediate health, safety, and personal rights risk to 1 (R1) of 64 residents in care.the state’s words, verbatim · CDSS document, Feb 24, 2025

Plan of correction: Licensee agrees to schedule an in-service training on the topics of care and supervision and send proof of scheduling to the Department by 2/25/25. Licensee agrees to send sign-in sheet and training topics to the Department by 3/17/2025.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Hannah Rodgers and Sabel Martinez conducted an unannounced Case Management visit to address a deficiency discovered during a complaint investigation. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Mike McCoy. The complaint investigation was regarding an altercation between Resident #1 (R1) and Resident #2 (R2). [See LIC811 Confidential Name List for identification of select person identifiers used in this report.] It was discovered the facility did not conduct a reappraisal of R2 to determine if the facility was an appropriate placement after R2, who exhibited multiple aggressive behaviors towards staff and residents. The facility did not reappraise the resident after the resident demonstrated behavioral expressions resulting in harm to others. This deficiency was cited in accordance with California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A plan of correction was jointly formulated with Executive Director McCoy. An exit interview was conducted with McCoy, to whom a copy of this report, LIC 809-D, LIC811, and Licensee Rights (LIC9058), were provided.the state’s words, verbatim · CDSS document, Feb 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(c)(3) · Plan of correction due date: Feb 24, 2025

Reappraisals (c) If the licensee observes or is made aware of behavioral expression, as defined in Section 87101, that has caused or may cause harm to the resident or others, the licensee shall document all of the following in the resident’s reappraisal: (3) Interventions to be implemented to minimize the risks to the health and safety of the resident or others associated with the resident's behavioral expression. The licensee shall use the least restrictive intervention to manage the behavioral expression based on the individual needs of the resident. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not ensure that R2 received a reappraisal after a significant change in condition and behavioral expression to minimize risks to other residents in care. This posed an immediate safety risk to 70 of 70 residents in care.the state’s words, verbatim · CDSS document, Feb 24, 2025

Plan of correction: Licensee agrees to schedule an in-service training on the topics of Reappraisals and recognizing residents change in behaviors and send proof of scheduling to the Department by 2/25/25. Licensee agrees to send sign-in sheet and training topics to the Department by 3/17/2025.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Assistant Resident Service Director Starsha Borja. Executive Director Mike McCoy and Resident Service Director Evalyn Valaile arrived during the visit. Today's visit was in response to a self-reported incident of Resident 1 (R1) found chewing on two pencil sharpeners during arts and craft resulting in staff finding two single razor blades in R1's mouth. [See LIC811 Confidential Names List.] During today’s visit, LPA performed a brief facility tour and welfare check on R1. LPA also collected copies of and reviewed R1's care and medical records. According to their latest LIC602 Physician’s Report, R1 was diagnosed with Alzheimer's disease and Dementia. Due to their baseline memory loss, R1 was not able to serve as a reliable historian/interviewee for this case. Staff interviews unanimously showed: Resident's are not to be allowed access to pencil sharpeners due to safety concerns. Sharpeners were to be used by staff to sharpen resident's pencils. Staff interviews further show: R1 has a history of putting inedible objects into their mouth and there is no consensus on how R1 obtained the sharpeners. Direct cares staff were supervising R1's floor (the first floor), activity staff were on the second floor conducting a different activity. One (1) deficiency was cited per California Health and Safety Code. An exit interview was conducted with Executive Director Mike McCoy and Resident Service Director Evalyn Valaile, to whom a copy of this report, the LIC811 Confidential Names List, the LIC809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Dec 30, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.312(e) · Plan of correction due date: Jan 29, 2025

1569.312 Basic services requirements: "(e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being." This requirement was not met as evidence by: Based on interview, the licensee did not comply with the section cited above in one (1) out of sixety-nine (69) residents which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 30, 2024

Plan of correction: Licensee agrees to conduct a training for their current direct care staff and activities staff on the topic of Monitoring Activities & Supervision. Licensee agrees to send training agenda and sign in sheet to CCL by POC date of 01/29/2024.

Allegation investigated: Staff did not prevent outbreak of covid.

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Resident Services Director Evalyn Valaile and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA observation, records review and interviews with facility staff, resident and outside sources. It was alleged that staff failed to prevent a covid outbreak. It was reported that Resident 1 (R1(an LIC 811 Confidential Names List was provided to the facility representative to identify the resident) was transported to the hospital due to labored breathing, where they subsequently tested positive for COVID-19. It was reported that additional residents on the first floor also tested positive for covid-19, leading to allegations that staff failed to prevent a COVID-19 outbreak in the facility. Unsubstantiated The facility has an infection control plan in place that includes isolating covid positive residents during their infectious period. This protocol was reviewed and found to have been followed appropriately in the cases reported. Interviews with staff confirmed that the positive residents were isolated, and proper protocols were implemented once covid cases were identified, including; two hour checks, food delivered to resident's rooms and covid testing for symptomatic residents. Records review revealed incident reports were submitted to CCL on August 14, 2024. The incident reports indicated that five residents tested positive for Covid-19 and were immediately placed in quarantine with a "PPE isolation cart" placed outside of their door. A transmission precaution sign was also placed on each of the resident's door. All of the covid positive resident's responsible parties and Physicians were notified. LPA interviewed several of the residents that were previously covid positive. All of the residents interviewed stated that they were instructed by facility staff to self isolate in their rooms. One of the residents interviewed stated that the covid positive residents had their meals delivered to their rooms while they were sick and infectious. While residents were encouraged to wear masks and utilize PPE, it was noted that adherence to these guidelines varied, particularly among residents with cognitive impairments who may not fully understand the necessity of such measures. An interview with an outside source (OS) revealed no knowledge or evidence to substantiate the allegation that staff did not take appropriate actions to prevent the COVID outbreak. OS noted that the facility seemed to be following recommended protocols. LPA interviewed Business Office Director (BOD) who stated that when a covid case occurs at the facility the resident is placed on isolation and PPE supplies are placed outside of their room. Meals are served in resident's room and disposable plates and utensils are utilized until the covid case is resolved. Vitals are taken "Q-shift" and PRN. Residents with covid symptoms are tested and all staff, visitors and residents are encouraged to wear masks. The investigation indicates that while the facility faced challenges inherent in caring for residents with cognitive impairments, it followed its established infection control protocols. Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid. An exit interview was conducted with Evalyn Valaile. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Evalyn Valaile whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 08-AS-20240903100613

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was allowed entry and discussed the purpose of the visit with Resident Services Director (RSD) Evalyn Valaile. According to the facility’s license, The facility is approved to serve seventy eight (78) elderly residents. Of which sixty eight (68) may be non-ambulatory and ten (10) may be bedridden. Hospice waiver approved for twenty (20) residents. LPA, accompanied by RSD toured the interior and exterior of the facility, and inspected several resident rooms on the first and second floor of the facility. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. Hot water temperature was measured in the facility at 115 degrees F. The ambient temperature inside the facility was measured at 75 degrees F. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas. Their are no pools/bodies of water on the premises. Per RSD, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-C] LPA reviewed multiple staff and resident records/files. Records review did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Evalyn Valaile whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Oct 24, 2024

Allegation investigated: Insufficient staffing to meet residents needs. Facility did not have adequate supplies to meet residents needs.

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Business Office Director Amanda Togia and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of LPA observation, records review and interviews with facility staff, resident and outside sources. It was alleged that staffing was not sufficient to meet resident's care needs. It was reported that their were not enough staff "NOC" staff to meet all of the residents’ care needs. A comprehensive review of staffing records was conducted for the months of June through August 2024. The records were assessed to determine the number of staff members scheduled and present during all shifts. The records review revealed that staffing levels consistently met the requirements set forth by regulatory standards and internal policies. LPA observed that the number of staff present at the facility was adequate to meet the residents’ needs. Unsubstantiated Records review further revealed that the resident census on the 1st floor and 2nd floor had an average of 36 residents. The AM staffing ratio on both floors was regularly at; three caregivers and one med-tech. The PM staffing ratio was regularly at three caregivers and one med-tech . The NOC staffing ratio was regularly at two caregivers and one med-tech for both floors. The staffing schedule also revealed an outside agency had been utilized to assist with staff vacancies. Analysis of staffing schedules showed that the facility maintained adequate staffing ratios to address the needs of residents. LPA interviewed a 2nd floor resident who stated that they have lived at the facility for 2.5 years. Resident stated that they are very happy at the facility. Resident stated the facility staff are "wonderful" and they feel "blessed" to live there. Resident further stated that they get "fast help from staff" whenever needed. It was also alleged that the facility did not have adequate supplies to meet residents needs. It was reported that the facility was low on various sanitary and medical supplies. It was also reported that staff did not have access to the supply room during the NOC shift. LPA visited the facility on July 29,2024. LPA inspected two supply rooms on the second floor. One main supply room with large boxes and supplies that was locked and a second unlocked supply closet with various materials and supplies stored on shelves. LPA observed that the facility had an adequate supply of materials necessary for resident care, including medical supplies, personal hygiene items, and other essential resources. A review of facility records revealed a supply invoice dated July 5, 2024. The invoice included a sufficient amount of small, medium, large, and extra-large adult briefs, wipes, and gloves. Interview with Resident Services Director (RSD) revealed that the main supply room can be accessed by two other staff members and the maintenance worker. RSD stated that the supply closet is available to all of the staff members and the main supply room can be accessed any time of day if needed. RSD further explained that although she purchases supplies for all of the resident's, some residents' choose to purchase their own incontinence supplies, etc. RSD explained that the main supply room has boxes labeled for specific residents that purchase their own supplies and/or receive supplies from various programs. ED stated that as a result the main supply room must be closely monitored so that staff members do not disperse the various supplies incorrectly. LPA reviewed the facility standardized admission agreement. The agreement revealed residents have the option of purchasing their own incontinence supplies or they can pay an additional monthly fee to have the facility provide the supplies. LPA interviewed outside agency (OA). OA also reviewed the facility’s supply inventory and agreed with the LPA’s assessment, confirming that the supplies available were sufficient to meet the residents’ needs. OA agency stated from their assessment the facility has sufficient staff to meet the needs of the residents. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. An exit interview was conducted with Amanda Togia. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Amanda Togia whose signature below verifies receipt of these rightthe state’s words, verbatim · CDSS document, Aug 29, 2024 · control 08-AS-20240812104805

Allegation investigated: Staff left resident in a soiled diaper for a prolonged period of time.

Licensing Program Analyst (LPA) Ryan Fulton conducted an unannounced 10-day visit to initiate a complaint investigation and deliver findings regarding the above mentioned allegation. LPA introduced himself and disclosed the purpose of the visit to Resident Services Director Nae Brownell. On 07/09/24, it was alleged that staff left resident in a soiled diaper for a prolonged period of time. The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff and residents, and a records review. Staff interviews revealed that the facility was changing residents promptly. Staff said they check resident rooms every two hours for incontinence care issues. Staff members advised that while some residents need more attention with incontinence care, they believe all residents receive the appropriate amount of care. Staff interview revealed that incontinence products were located in a locked storage room that is accessible to staff. Resident Interviews did not corroborate the allegation; residents informed that the facility kept them clean and changed them regularly, and they are not being left in soiled diapers for a prolonged period. (Continued on LIC9099C) Unsubstantiated Residents interviewed did not expressed concern regarding incontinence care being not satisfactory. A review of facility records revealed invoices for incontinence care products were regularly purchased for the facility residents. The invoice consisted of small, medium, large, and extra-large adult briefs, wipes, and gloves. Records also indicated that the facility staff did in-service training for incontinence care, which included how to properly change residents with incontinence care and care for incontinence needs in older adults. LPA observations revealed a sufficient amount of incontinence products in the backstock area. LPA also observed that the facility was not malodorous of urine or feces. Outside sources revealed that residents are well taken care of, and they had no issues with incontinence care for their client. This agency has investigated the complaint alleging staff left resident in a soiled diaper for a prolonged period of time. The department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred, therefore the above allegation is found to be UNSUBSTANTIADED. An exit interview was conducted, and report was reviewed with the licensee/facility representative.the state’s words, verbatim · CDSS document, Aug 21, 2024 · control 08-AS-20240709103241

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA was greeted by and met with Executive Director Rob McFarlane, to discuss the purpose of the visit. Today's visit is in response to the self reported incident of Resident 1 (R1 - see LIC811 Confidential Names List) who was found with their arm wedged inside of guard rail resulting in a radial fracture. LPA interviewed staff and obtained facility records. R1 remained hospitalized at the time of the visit. No deficiencies were cited or observed on this date. An exit interview was conducted with Rob McFarlane, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 8, 2024

Allegation investigated: Lack of supervision resulted in resident on resident altercations

Licensing Program Analysts (LPA) Iby Strong and Ryan Fulton conducted an unannounced visit to initiate a complaint investigation. LPAs identified themselves and discussed the purpose of the visit with Resident Services Director Nae Brownell. On July, 9, 2024, Community Care Licensing (CCL) received a complaint alleging staff lack of supervision resulted in resident on resident altercations. During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. Based on Resident 1 (R1) Physician’s Report dated April 2, 2024, R1 can communicate need and can follow instructions. According to allegations, on two separate occasions, residents were not supervised resulting in R1 being hit by Resident 2 (R2) causing R1 a minor injury then and on a separate occasion R1 was scratched by Resident 3 (R3). Unsubstantiated Continuation from LIC9099 According to staff present on date of first incident, July 5, 2024, R2 was having a behavior and injured R1 causing a minor bruise to the shoulder. Staff revealed they observed the incident and provided care for R1. Staff also revealed that on another date, July 7, 2024, R3 became upset at R1, resulting in R3 scratching at R1. Staff revealed that R1 received first aid and residents were separated immediately. According to interviews, staff observed both incidents. Interview with outside sources revealed that staff acts quickly in urgent events, and there is no issue with the supervision provided to the residents in care. Lastly, records reviewed revealed facility documented events properly and have also addressed R2 and R3’s behaviors to prevent future instances. During investigation, there was no corroborating information found to determine lack of supervision resulted in resident-on-resident altercations. Based on LPA's interviews with staff, outside source interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Resident Services Director Nae Brownell, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jul 16, 2024 · control 08-AS-20240709113951

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ryan Fulton conducted an unannounced Case Management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Resident Services Director Nae Brownell , and we discussed the purpose of the visit. Community Care Licensing received an incident report on 7/09/24 in which it was reported that Resident #1 (R1) went absent without official leave (AWOL) from the facility on 7/06/24. R1 left the community at approximately 11:18 am via GoGo Driver and returned to facility at approximately 12:24 pm. Per records reviewed licensee followed absentee notification plan as necessary. During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation. LPA Fulton observed auditory alarm installed in the memory care cottage. No deficiencies were cited during today’s visit. An exit interview was conducted with Resident Service Director Nae Brownell who was also provided a copy of their appeal rights (LIC9058 03/22), LIC811, this report and their signature on this form, acknowledges receipt of these rightsthe state’s words, verbatim · CDSS document, Jul 10, 2024

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Ryan Fulton and Nacole Patterson conducted an unannounced Case Management - Incident visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Directors Stefanie Ancheta and Rob McFarlane. Today's visit was in response to an LIC624 Incident Report and a Soc341 Abuse Report which licensee self-submitted to the CCLD San Diego Regional Office (received on 06/12/2024), involving Resident #1 (R1) and Resident #2 (R2). During today’s visit, LPAs performed a facility tour / welfare check and collected records. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Executive Directors Stefanie Ancheta and Rob McFarlane, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jun 13, 2024

Allegation investigated: Neglect/lack of supervision resulting in sexual abuse. Neglect/lack of supervision resulting in felony drug use. Licensee retained residents that are incompatible with other residents in care.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Amanda Togia, Business Office Director. On 2/28/23 the following allegations were made against the Licensee: Neglect/lack of supervision resulting in sexual abuse, neglect/lack of supervision resulting in felony drug use, Licensee retained residents who were incompatible with other residents in care. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "Neglect/lack of supervision resulting in sexual abuse", it was alleged that staff did not prevent Resident (R1) from taking sexual advantage of Resident 5 (R5), and staff did not prevent Resident 3 (R3) from inappropriately touching Resident 6 (R6). Staff members interviewed consistently denied that either event occurred, informing that residents are not allowed in other residents' rooms. (Continued on LIC9099-C p.2) Unsubstantiated (Continued from LIC9099 p.1) No staff interviewed had observed or been told that any resident was being forced to do something outside of their will. Staff interviews further revealed staff's awareness of residents' rights to have consensual intimate relations, per Title 22, Section 87468.1(b)(7)(A). Staff informed that R1 and R5 sometimes walk around the facility holding hands, and R3 and R6 had a close friendship that R6's family approved of. Outside source interviews corroborated staff statements regarding R3 and R6's relationship, stating they were happy about it and had no concerns. Resident interviews did not corroborate the allegation. No records were found to corroborate the allegation or that either alleged event occurred. Regarding the allegation, "Neglect/lack of supervision resulting in felony drug use", it was alleged that the Licensee allowed Resident 3 (R3) to bring illegal drugs into the facility. Staff interviews revealed that a substance was found among R3's possessions prior to moving into the facility, but it was discarded and not tested to confirm what the substance was. Staff members interviewed consistently denied that any resident had used illegal drugs at the facility, including R3. Resident interviews revealed that no resident had knowledge of any illegal drug use at the facility, including R3, who denied ever using drugs at Heritage Hills. Outside source interviews did not corroborate this allegation. No records were found to support that this alleged event occurred. Regarding the allegation, "Licensee retained residents who were incompatible with other residents in care", it was alleged that the Licensee had admitted homeless persons and drug addicted persons into the facility who did not have memory care issues. Records were reviewed regarding the residents in question- Resident 1 (R1), Resident 2 (R2), Resident 3 (R3), and Resident 4 (R4). The records revealed that the residents in question had the following assessments and/or appraisals prior to being admitted into the facility: Physician's Report (LIC602), Pre-admission Assessment, Needs & Services plan. R1 and R3’s files contained an additional Resident Appraisal, while R2 and R3’s files contained an additional Mini Mental exam confirming cognitive impairments. The records found were consistent with pre-admission records for all other residents prior to being accepted to live in the facility. The LIC602 forms revealed that R1, R2, R3, and R4 were all diagnosed with memory issues and/or Dementia, which was consistent with the population that the facility serves as a memory care facility. (Continued on LIC9099-c p.3) (Continued from LIC9099-C p.2) Staff interviews confirmed that R1, R2, R3, and R4 were assessed prior to living at the facility, upon moving in, and ongoing as their conditions changed, as any other resident in the facility would be. Staff members interviewed consistently affirmed that the residents in question were compatible for the facility based on their cognitive needs, care needs, and behavior levels. No staff interviewed informed that any of the residents in question were not an appropriate fit to live at the facility. Outside source interviews did not corroborate the allegation. Based on interviews, direct LPA observations and records review, the investigation did not yield a preponderance of evidence to conclude that the allegations of neglect/lack of supervision resulting in sexual abuse, neglect/lack of supervision resulting in felony drug use, and Licensee retained residents who were incompatible with other residents in care occurred. Based on the foregoing, the allegations are unsubstantiated. An exit interview was conducted with Amanda Togia, Business Office Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 31, 2024 · control 08-AS-20230228111919

Allegation investigated: Staff did not seek medical attention for residents.

Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to deliver investigation findings. LPA was granted entry into the facility and met with Stefanie Ancheta, Executive Director, to whom LPA disclosed the reason for the visit. It was reported to Community Care Licensing that Resident 1 (R1) had a seizure for which 9-1-1 was not called. It was also reported that Resident 2 (R2) fell and hit his/her head, following which staff arrived 30 minutes later and put R2 back into the bed without conducting an assessment or calling 9-1-1. Community Care Licensing (CCL) has investigated the above-listed complaint allegation. The investigation consisted of a tour of the facility, review of facility records, and interviews of staff and outside source. Records obtained and reviewed during the investigation reflected that R1 had documented seizure activity. It was also noted that R1 was transported to the hospital, on occasion, following seizure activity. It was further Unsubstantiated noted that R1 was prescribed medication to address the seizure activity. The investigation did not yield evidence that indicated that immediate or emergency medical attention was needed each time R1 exhibited seizure activity or that R1 experienced a seizure following which needed medical attention was not sought. Additionally, the investigation produced no evidence that R1 experienced a seizure at the time of the alleged incident. Records retained relative to R2 reflected that R2 was at risk for falls. Interviews also yielded that the facility had procedures in place for staff to follow in response to resident falls. The investigation did not yield evidence of a fall sustained by R2, following which R2 was not assessed or that needed medical attention was not sought. Based upon the foregoing, the allegation is unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted with Stefanie Ancheta, and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to the Executive Director at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 27, 2024 · control 08-AS-20230429075042

Allegation investigated: Unlawful Eviction

Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced complaint visit. LPA gained access to the facility and met with Administrator, Stefanie Ancheta and explained the purpose of the visit which was to initiate a complaint investigation. Upon conclusion of the facility visit, LPA delivered findings for the above allegation to Ms. Ancheta. The Department’s investigation consisted of visits to the facility, resident records reviews and interviews with pertinent staff and outside sources. It was alleged Resident 1 (R1) was unlawfully evicted from the facility. Record reviews indicated that R1 had displayed aggressive behaviors towards residents and staff four times. R1’s changes in behavior were documented in appraisals, physician reports and physician progress notes. R1’s aggressive behaviors caused injury to residents. Upon move in, R1’s Power of Attorney signed the facility’s admission agreement which reads in part, "#3 Residents must not engage in conduct that poses a danger to themselves or others at the community, Unfounded must not be disruptive, must not create unsafe conditions, and must not be physically or verbally abusive to other residents or staff." Records reviewed provide support that R1’s behavior violated the facility’s terms which was digitally signed by R1’s POA on 11/23/2022. LPA reviewed the facility’s 30-day notice of eviction and confirmed it meets the requirements in Title 22 Regulations. Based on records reviews and interviews with pertinent staff and outside sources, the complaint allegation is determined to be Unfounded, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, as to the above listed allegation, the facility followed Title 22 regulation at this time, and the Department has dismissed the complaint. An exit interview was conducted with Ms. Ancheta and a copy of this report and Licensee/Appeal Rights (LIC 9058 01/16) were provided to the following the visit. Ms. Ancheta’s signature below confirms receipt of the records.the state’s words, verbatim · CDSS document, Feb 28, 2024 · control 08-AS-20240221104203

Allegation investigated: -Staff did not ensure resident was provided with adequate bed linens -Staff did not adequately assist resident with activities of daily living -Staff did not inform resident's physician of a change in resident's condition

Licensing Program Analyst (LPA) Daniel Pena conducted a visit to the facility to initiate a complaint investigation. After identifying himself and providing the purpose of the visit, LPA was allowed into the facility where he was met by Administrator, Stefanie Ancheta. Upon the conclusion of the visit, LPA provided Ms. Ancheta with investigative findings. On 02/27/2024, the Department received this complaint which alleges; Staff did not ensure resident was provided with adequate bed linens; Staff did not adequately assist resident with activities of daily living; and Staff did not inform resident's physician of a change in resident's condition. The Department's investigation consisted of facility inspection, LPA observation, record reviews and interviews with staff and outside sources. LPA, accompanied by Ms. Ancheta, toured the facility's memory care unit. LPA observed that each of the resident's bed obsereved had linens which appeared clean and without foul odor. LPA observed the facility's supply Unsubstantiated area and noted fresh linen in adequate numbers to provide residents with bedding. Based upon LPA observation, there was no evidence observed to support the allegation that the facility did not provide residents with adequate bed linens. LPA reviewed Resident 1 (R1)'s records as part of this investigation. LPA observed that R1 has Alzheimer’s and Dementia diagnoses. According to R1's appraisal and physician reports, R1 requires assistance with bathing, hair care, personal hygiene, medications, observation for wandering, cash resources and activity programs. Interviews and record reviews did not provide support that R1 did not receive assistance with the aforementioned Activities of Daily Living (ADL). LPA reviewed R1's appraisals and progress notes prepared by R1's primary care physician. LPA also reviewed R1's medication list and changes ordered by R1's primary care physician. Records provide consistent documentation that R1's physician noted no concerns with care provided by facility staff. R1's medication records did reflect changes in R1’s condition and medications were ordered to address them. The Department has investigated the allegations as mentioned above. Based on LPA observation, record reviews and interviews the investigation failed to produce sufficient evidence to corroborate the allegations. The preponderance of evidence standard was not met; therefore, the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Ms. Ancheta, whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Feb 28, 2024 · control 08-AS-20240227093832

Allegation investigated: Staff do not meet residents' dietary needs Staff do not report incidents to appropriate parties

Licensing Program Analyst (LPA) Mark Mandel conducted an unannounced visit to follow-up on a complaint investigation regarding the above-mentioned allegations. LPA was greeted by, identified himself to and was granted entry by Business Office Director, Amanda Togia. LPA stated the purpose of the visit and discussed the elements of the complaint with Director Togia. LPA delivered the investigative findings to Director Togia. Today's visit consisted of staff interviews and records review. The Department’s investigation consisted of facility visits, record reviews, and interviews with staff, residents and outside sources. On 12/28/2023, the Department received a complaint alleging that facility staff do not report incidents to the appropriate parties; however, the only incident that was spefically described and corrobated to have occurred after interviews with staff was determined to have been reported to all the appropriate parties. A review of the number of Unusual Incident Reports reported to Commnity Care Licensing in 2023 was 274, including 16 involving abuse from one resident to another (Cont. on LIC9099) Unsubstantiated (Cont. from LIC9099) where a SOC341 was filed with the Unusual Incident Report, as required. These reports are an indication that incidents are reported to the appropriate parties. Specifically, Staff 1(S1) stated that she is the one who normally reports incidents to the appropriate parties, including the ombudsman, doctor and family of residents involved, Community Care Licensing Division and Law Enforcement, if necessary, once she is informed of an incident by her staff, who she said complete an internal report using a program called Point Click Care. S1 also said she is currently training Staff 2 (S2) to assist in completing all of the required reporting for unusual incidents and that S2 has done all the reporting required for some incidents, but is still being trained. S2 was able to state the external reporting requirements, as well as her internal ones, to LPA when asked. Although Interviews with residents revealed that they did not know what the reporting requirements were for staff when an unusual incident occurs, they did indicate that staff responded appropriately to unusual incidents. It was also alleged that staff do not meet residents' dietary needs. During a tour of the facility, LPA observed lunch being served to residents in the dining room, and the meal included hot dogs, French fries, fruit and beverages. Staff interviews confirmed residents are served three meals a day, plus snacks. LPA also reviewed the menu for a week, which showed three meals are served daily, along with two snacks. The breakfast meal consist of a variety of choices, including hot or cold cereal, along with eggs, a meat item, waffles or similar item, among other choices and beverages. The choices for lunch included, but were not limited to Philly Cheesesteak, Fried Shrimp, Chili dogs and Chicken Burgers served with fruit, beverages and other side items. Weekly dinner choices included, but were not limited to Pork ribs, beef stew, spaghetti with meatballs and chicken Parmesan served with vegetables and a starch like rice, beans, potatoes and/or bread, and other side items and a beverage of choice. LPA also reviewed an A La Carte Menu, which included a choice of sandwiches, eggs, burgers, fish, fruit and other items, and staff and resident interviews confirmed this optional menu was available to order from if residents did not want the items being served from the main menu. Interviews with residents and outside sources also confirmed that residents are served three meals a day, plus snacks, along with beverages, and all residents interviewed stated that the food was either really good or good, except for R1, who stated the food was fine overall, but could be better and was served at room temperature 80% of the time, but if R1 asked for their food to be reheated they said that request was met. (Cont. on LIC9099) (Cont. from LIC9099) No other residents complained about the temperature of food served; however, S1 stated she had heard complaints about residents' food being cold, but said that problem was during a COVID Outbreak from 11/30/2023 to 12/21/2023 when residents were all being served meals in their rooms instead of using the dining room in order to limit the spread of COVID. S1 said meals were transported to rooms in "Hot Boxes", but the Hot Boxes slowly cool once they are unplugged from the wall, so residents served towards the end of a meal service, as opposed to at the beginning, were more likely to have meals served to them that had cooled. Interviews with residents and outside sources also supported the conclusion that the food variety was either good or very impressive. Interviews with residents and staff also supported the conclusion that fruits and vegetable are served daily and fresh fruits and vegetables are served as often as daily or when they are available. Based on LPA observations, interviews conducted and records obtained and reviewed, the allegation that facility staff do not meet residents' dietary needs and do not report incidents to appropriate parties is Unsubstantiated, as the preponderance of evidence standard was not met. An exit interview was conducted with Business Office Director, Amanda Togia. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to Director Togia, and their signature on this report confirms receipt of the report. .the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 08-AS-20231228124435

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to observe the physical plant. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Culinary Director Seven Ennis. On 07/10/2023, the Licensee submitted an LIC200 Application to the CCLD San Diego Regional Office (RO) requesting to increase the facility's total licensed capacity from seventy four (74) residents up to seventy-eight (78) residents. The facility’s floor plan remained unchanged. On 09/15/2023, the local fire authority approved/granted an updated fire clearance, reflecting the facility was approved for seventy-eight (78) residents in total, of which up to sixty-eight (68) may be non-ambulatory and up to ten (10) may be bedridden. During today’s visit, LPA briefly toured the interior and exterior of the facility. LPA also inspected the four bedrooms (i.e., Rooms #205, #210, #212, and #215) which Licensee intends to turn from private to shared, finding that each of these bedrooms had sufficient space to comfortably house two residents and their required furnishings. The facility sketch/floor plan was consistent with the current layout of the facility. No deficiencies were observed or cited during today's visit. This portion of the application process has been completed. The Licensee will be sent an updated license to reflect the new fire clearance after CCLD management’s final review and approval. An exit interview was conducted with Ennis, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Nov 9, 2023

Allegation investigated: Lack of supervision resulted in resident sustaining injury.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Executive Director Stefanie Ancheta. On 3/29/23 it was alleged that lack of supervision resulted in a resident sustaining an injury when a resident (R1) had an episode of physical aggression against another resident (R2). The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, and outside sources. Staff interview revealed that residents R1 and R2 were directly observed by staff (S1) at 4:00pm and found to be at baseline with no visible injuries; residents were checked again at 4:30pm and R2 was found with minor injuries, noted as bruises. Records review revealed that on the day of the event, R2 had been visited by an outside agency for care and an outside individual for visitation; neither party noted injury for R2 prior to staff observation. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) Staff interview and records review revealed that the incident was investigated internally, confirming that R1 experienced an acute symptom of physical aggression from a preexisting medical condition. Staff interviews and records review showed that staff documented the behavioral incident, assisted both residents with medical care, and notified resident physicians and the Responsible Parties timely. Outside sources interviewed stated that the facility had supervision concerns during the timeframe of the complaint allegation; however, no interviews or records corroborated that there was a lack of supervision at the time of the incident. Based on interviews, observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Stefanie Ancheta , to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 6, 2023 · control 08-AS-20230329120448

Allegation investigated: Staff failed to meet residents' needs.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Executive Director Stefanie Ancheta. On 6/21/23 it was alleged that staff did not meet residents' needs due to residents having to wait long periods of time for their meals. The Department’s investigation consisted of unannounced facility tours, review of facility and outside source records, interviews with facility staff, residents, outside sources, and LPA direct observations. Staff interviewed had not observed delays in food service and had not been notified by residents or their responsible parties of food delays. Staff interview revealed that over the past few years the breakfast time has changed from 7:30am, to 8:00am, to 8:30am, possibly causing confusion between residents and staff regarding what time breakfast is served. Residents interviewed provided mixed opinions regarding the timing of food service but informed that overall, food was served on time. Outside source interviews revealed that food was served on time or early. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) Records review and LPA observations revealed that the facility has meal times posted on the activities calendar on each floor and snack times posted on the weekly menus. LPA directly observed mealtimes during prior unannounced visits and did not observe or hear concerns from residents, staff or Responsible Parties that food service was consistently late. Based on interviews, direct LPA observations and records review, the investigation did not yield sufficient evidence to conclude that staff failed to meet the needs of residents. Based upon the foregoing, the allegation is UNSUBSTANTIATED. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director Stefanie Ancheta, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 6, 2023 · control 08-AS-20230621145001

Allegation investigated: Licensee did not address Scabies outbreak. Licensee did not assist resident(s) with showering.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Executive Director Stefanie Ancheta. On 6/6/23 it was alleged that Licensee did not address Scabies outbreak, and Licensee did not assist resident(s) with showers. The Department’s investigation consisted of unannounced facility visits, review of facility records, interviews with facility staff, residents, outside sources, and LPA direct observations. Regarding the allegation, "Licensee did not address Scabies outbreak", it was alleged that Licensee did not take measures to prevent Scabies from spreading at the facility. Staff interview revealed that staff identified the first cases, elevated the issue, and management trained/implemented the infection control protocol the same day of the first confirmed case. All staff interviewed consistently recited the infection control protocols for Scabies and stated they felt comfortable with the steps taken to protect residents and staff. Records review revealed that management contacted the CDC, CCLD, Responsible Parties, and the doctors for affected residents. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) Records review corroborated that an in-service training was conducted for staff regarding Scabies infection control and contact precautions. During an unannounced facility visit LPA directly observed evidence of the infection protocols in place such as PPE carts outside of resident rooms, increased cleaning of common surfaces by housekeeping staff, and quarantine signs on resident doors. Regarding the allegation, "Licensee did not assist resident(s) with showering", it was alleged that residents were not being showered according to their care plans. Staff interview responses were varied and inconsistent, some staff stating that showers were offered multiple times but refused by residents, other staff informing that showers were being given consistently, and additional staff informing that certain shifts were not consistently showering residents. Residents interviewed stated that showers were being provided consistently and on time. Records review showed that staff were not consistently completing the shower and body check logs during the timeframe of complaint, resulting in the absence of recorded proof if showers were being provided. Outside sources interviewed could not speak to consistency of showers. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Stefanie Ancheta, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 6, 2023 · control 08-AS-20230606163351

Allegation investigated: Facility did not administer medication to resident, as prescribed. Lack of supervision resulted in resident elopement.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Executive Director Stefanie Ancheta. On 4/4/23 it was alleged that the facility did not administer medication to a resident as prescribed, and that lack of supervision resulted in a residents' elopement. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, and outside sources. Regarding the allegation, "Facility did not administer medication to a resident, as prescribed", it was alleged that a resident (R1) received a pro re nata (PRN) medication too soon within the prescription orders, and did not receive a medication after the facility received it. Staff interview and records review revealed that R1 received the PRN within the required timeframes on the day in question. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) Staff interview further revealed that there had been ongoing confusion and communication issues between the facility and pharmacy, resulting in instances where it was unknown if a medication had been sent out, received, or should be administered. Outside interviews corroborated the communication issues, informing that the outside agency and the facility were in communication to correct the issues. No records reviewed corroborated that staff administered medication outside of R1's prescription. Regarding the allegation, "Lack of supervision resulted in resident elopement", it was alleged that a resident eloped from the facility due to staff not providing adequate supervision. Staff interview showed that internal investigation of the incident was conducted, revealing that multiple delayed egress doors could be deactivated at the same time. This issue resulted in a resident exiting from the opposite side of the building while staff were addressing a different resident who had pushed the delayed egress door. Resident interview corroborated that the resident was able to exit through a different door during the same time the delayed egress door was pushed on the opposite side of the building. Records review revealed that staff Outside sources interviewed stated that the facility had supervision concerns during the timeframe of the complaint allegation; however, no interviews or records corroborated that there was a lack of supervision at the time of the incident. Records review, corroborated by staff interview, revealed that staff responded immediately to the delayed egress door and located the resident who had activated it. Based on the evidence gathered, the cause of the elopement was due to the unknowingly linked door system; no evidence was found to support that the elopement was due to lack of supervision. Case Management was provided with the Licensee regarding correcting the door system issue. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Stefanie Ancheta, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 6, 2023 · control 08-AS-20230404114645

Allegation investigated: Staff did not administer medication as prescribed. Licensee did not ensure resident(s) had access to personal care supplies.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation(s). LPA was welcomed by and discussed the purpose of the visit with Executive Director Stefanie Ancheta. On 2/15/23, it was alleged that staff did not administer medication as prescribed, and Licensee did not ensure resident(s) had access to personal care supplies. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, outside sources, and LPA direct observations. Regarding the allegation, "Staff did not administer medication as prescribed", it was alleged that a staff member intentionally withheld a resident's pro re nata (PRN) medication when the resident needed it. Staff interview revealed that the resident in question received the PRN medication the day of the incident and that staff monitor residents, assisting with their behaviors when necessary. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) Records review did not corroborate the allegation, and confirmed that residents exhibiting aggression and/or distress were given PRN medications according to their prescriptions. Resident interviews were not possible due to impaired cognition. LPA observations revealed staff members assisting residents with Activities of Daily Living (ADLs) and redirecting them as necessary. Regarding the allegation, "Licensee did not ensure resident(s) had access to personal care supplies", it was alleged that the Licensee did not ensure protocols were in place for resident personal care supplies to be maintained. Staff interview did not corroborate the allegation, as staff interviewed exhibited knowledge of the Responsible Party notification process when additional care supplies were needed. Records review revealed that the expectation was for residents and/or their Responsible Parties to provide personal care and hygiene supplies, with an agreed-upon option to pay an additional fee if they preferred the facility to provide these items. LPA observations revealed that the facility has had an emergency stock of personal care supplies, including briefs and incontinence supplies, if a resident ran out before their Responsible Party could bring more. Based on interviews, observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Stefanie Ancheta, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from LIC9099) Outside source interviews corroborated the allegation, revealing that a staff member exhibited impatience for a resident and spoke about them to others in a way that was disrespectful to the resident. Records review also corroborated this allegation, showing that the staff member in question (S2) was terminated due to inappropriate conduct toward residents and staff. Staff interviews corroborated that staff were instructed to provoke a resident. Regarding the allegation, "Staff did not meet resident(s) incontinence needs", it was alleged that staff did not assist residents timely with their incontinence needs. Staff interview revealed that staffing levels were low during the timeframe of the complaint, resulting in staff not being able to assist residents immediately when they had incontinence needs. Outside source interview revealed that residents were left in saturated briefs for long periods of time without being assisted and the resident floors had a strong smell of urine. Resident interview corroborated that night staff did not assist residents with incontinence care. During an unannounced facility visit on 2/22/23 LPA directly observed residents walking around with soiled briefs and a strong odor in the facility of incontinence. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Stefanie Ancheta, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 6, 2023 · control 08-AS-20230215104856

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Nov 6, 2023

87468.1(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met, as evidenced by: Based on interviews, Licensee did not accord 1 of 70 residents (R1) dignity in their personal relationships with staff. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 6, 2023

Plan of correction: Licensee terminated staff member S2, effective 6/22/23. Licensee agreed to coordinate retraining of all staff on 87468.1 Personal Rights, and to submit the training sign-in sheet(s) to LPA by the POC due date, as proof.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2)(3) · Plan of correction due date: Nov 6, 2023

87625(b)..."Licensee shall be responsible for ensuring (2)...that incontinent residents are checked... when they are known to be incontinent...(3) incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met, evidenced by: Based on interviews and observations, Licensee did not: check residents when known to be incontinent, ensure residents' were clean/dry, or ensure the facility remained free of odors of incontinence. This posed a potential health risk to 70 of 70 residents in care.the state’s words, verbatim · CDSS document, Nov 6, 2023

Plan of correction: Licensee agreed to coordinate retraining of all staff on 87625 Managed Incontinence, and to submit the training sign-in sheet(s) to LPA by the POC due date, as proof.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Administrator Stefanie Ancheta, after identifying herself and stating the purpose of the inspection. The facility serves 74 non-ambulatory residents, age 60 and above, of which 10 may be bedridden, and currently has 69 residents in care. There is an approved Hospice Waiver for 20 residents. This is a two-story complex, equipped with delayed egress and secured perimeters. LPA was accompanied by the Administrator Ancheta during a tour of the facility. Tour was conducted inside and out and included a sample of 4 resident units, the dining area, recreation rooms, and food storage areas. Signal system are in place and operational. The last disaster drill was conducted on October 8, 2023. No bodies of water are on premises. Passageways were free from obstructions. According to Administrator, there are no weapons and/or ammunition stored on the premises. Pull cords were available in each resident unit and were tested for functionality. Delayed Egress and secured perimeter doors were also tested for functionality. Resident's room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens. All extra linens towels, and washcloths are all accessible in locked hall closet. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars, however the resident’s rooms inspected did not have non-skid strips or mats. Hot water temperature in residents’ bathrooms were compliant. [CONTINUED ON LIC 809-C]t [CONTINUED FROM LIC 809] Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked areas.. The medication room is secured and has a locked medication cart, emergency supplies, and medications were labeled and kept in compliance with label instructions. Staff records review verified that all staff have a current First Aid certificate and at least one staff member, per shift, has a First Aide/CPR certificate, Criminal Record Clearance, Personnel Record, TB clearance, and Health Screening Report, and required training. Resident records reviewed for a current Physician's Report, Resident Appraisal, Needs & Services Plan, Identification and Emergency Information, Admission Agreement, and Centrally Stored Medication. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. Conducted a thorough review of In-service training procedures. Transportation procedures were reviewed and complaint. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. An exit interview was conducted, this report was discussed with Administrator Ancheta copy along with Licensee/Appeal Rights (LIC 9058 01/2106), and their signature on this form acknowledges receipt and a copy of the report was given to the Administrator Ancheta .the state’s words, verbatim · CDSS document, Oct 23, 2023