Heritage Pointe

Allegation investigated: Staff did not provide requested record(s) to resident’s representative in a timely manner.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Executive Director Georgi Mendez and explained the reason for the visit. The investigation into the allegation, staff did not provide requested record(s) to resident’s representative in a timely manner, revealed the following. It was reported that the responsible party for Resident 1 (R1) requested R1's records including assessments and incident reports for R1. A review of records showed R1's responsible party requested R1's records via email on August 7, 2026. According to the Health and Safety Code, enumerated rights, severability,1569.269(a)(21) residents have the right, "To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies." LPA interviewed the Executive Director who reported that they received the request but have not provided the requested documents. The Executive Director reported the documents are being prepared and will be provided by August 14, 2026. Substantiated Based on the evidence gathered the facility has not provided the requested documents in the specified time frame therefore, the preponderance of evidence standard has been met; the allegation is deemed substantiated. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was provided to the Executive Director.the state’s words, verbatim · CDSS document, Aug 13, 2026 · control 22-AS-20260809130809

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(21) · Plan of correction due date: Aug 21, 2026

To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement was not met as evidenced by... R1's responsible party requested R1's records on August 7, 2026, but has not received the documents, this poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: Administrator agrees to provided the requested documents by August 14, 2026 and to sign a statement of understanding for HSC 1569.269. Proof of correction to be provided to the LPA by the POC due date.

Allegation investigated: Delayed Egress not working properly in Memory Care

Licensed Program Analysts (LPAs) Joseph Alejandre and Taylor Simerly arrived to begin the investigation into the allegation above. LPAs met with Director of Memory Care and Sage, Miguel Silva and explained the reason for the visit. The investigation into the allegation revealed the following; it was reported that the delayed egress doors in memory care were not working properly. LPAs interviewed Director of Memory Care and Sage who reported that the delayed egress doors in memory care have always been working properly. LPAs toured the facility and memory care. The facility is approved for 3 delayed egress doors in memory care. One of the doors is located in the memory care outdoor patio. LPAs tested all three delayed egress exit doors in memory care and all three doors were found to be operational with no issues. LPAs interviewed maintenance director, who stated that there are no problems with delayed egress doors in memory care. LPAs did not observe any obstacles or hazards in memory care. Unfounded The evidence gathered refutes the allegation. Based on the evidence gathered the allegation is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with the Director of Memory Care and Sage and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 5, 2026 · control 22-AS-20260730124347

Type of visit: Case Management - Other

Licensing Program Analysts (LPA) Joseph Alejandre and Taylor Simerly made an unannounced visit to conduct a case management visit. LPAs met with Miguel Silva, Director of Memory Care and Sage and explained the reason for the visit. On July 31, 2026, the Agency received a special incident report (SIR) that Resident 1 (R1) left the facility unattended on July 27, 2026. On July 27, 2026 at 12:58 pm staff observed that R1 was missing. Staff began searching for R1 in the nearby neighborhoods. R1 was found down the street and law enforcement was called. R1 was assessed by paramedics and determined there was no need to transport R1 to the hospital. Paramedics released R1 to facility staff and staff transported R1 back to the facility. R1's family then discharged the resident from the facility that same day around 6pm. A review of records show that R1's last doctor's visit was on June 5, 2026. R1's physician report LIC602A states that R1 has been diagnosed with Dementia and cannot leave the facility unassisted. The Director of Memory Care and Sage reported that they have provided training to their staff and increased safety checks. The Director of Memory Care and Sage stated that the employee who left the gate propped open and allowed R1 to elope was terminated at the start of their next shift the following day. Facility is responsible for R1 and R1 resided in memory care. Staff verified R1 left the facility unattended. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.the state’s words, verbatim · CDSS document, Aug 5, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 6, 2026

(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... R1 left the facility unattended on July 27, 2026, R1 is not allowed to leave the facility unassisted, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 5, 2026

Plan of correction: Licensee already conducted an in-service training for all staff members on CCR 87464 and will provide a copy of the sign-in sheet for all staff in attendance. Licensee agrees to provide an outline of topics covered in the in-service, including the duration of the in-service training and a list of all participants. Proof of correction to be sent to the LPA.

Allegation investigated: Staff neglect resulted in a resident sustaining an injury from multiple falls Staff left a resident unattended while being transported to the hospital

On this day, Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to the facility for the purpose of following up on the investigation of the allegations listed above and delivering findings to the licensee. LPA was greeted and granted entry by facility staff after introducing themselves and stating the reason for the visit. Administrator Georgianna Mendez was present on the premises and assisted with the visit after being presented with the four allegations under review. The initial complaint investigation visit was conducted on March 28, 2024. During the visit, LPA requested and obtained records maintained at the facility for resident R1. A follow-up visit took place on July 22, 2025, with additional records requested. Additional interviews attempted or conducted during the investigation. Continue on LIC9099-C Unsubstantiated Resident R1 was admitted to the facility on September 30, 2013 with a primary diagnosis of hypertension and no initial indication of major neurocognitive disorders at the time of admission. R1 was discharged from the facility on January 9, 2024. Regarding the allegation that Staff neglect resulted in a resident sustaining an injury from multiple falls: Based on the evidence gathered, there have been multiple instances of fall incidents sustained by R1, at least one of which resulted in injury and hospital treatment. The evidence gathered is however insufficient to clearly establish that the falls were attributable to staff neglect rather than to changes in the resident’s condition. The allegation is therefore found to be Unsubstantiated. Regarding the allegation that Staff left a resident unattended while being transported to the hospital, the following has been concluded: After a fall sustained on December 8, 2023, R1 was first transported via EMS to Hoag Hospital in Irvine before being transferred to Hoag Hospital Newport Beach at the neurosurgery department due to a suspicion of a subdural hematoma. A review of the resident records maintained at the facility also allowed LPA to corroborate that the responsible party for the resident had been contacted by the facility staff following the fall. A fax reporting the fall to the resident's physician was also located. Report states that EMS had initially informed the facility that the resident would be transported to Saddleback MemorialCare but was re-routed to Hoag Irvine for unknown reasons which appears to explain why R1’s responsible party had to actively attempt to locate the resident following admission. A copy of R1’s Consent for Emergency Medical Treatment was present and on file. As resident was placed under the responsibility of EMS personnel, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative. Resident R1 was admitted to the facility on September 30, 2013 with a primary diagnosis of hypertension and no initial indication of major neurocognitive disorders at the time of admission. Subsequent appraisals were conducted and reviewed, including updates to R1’s plan of care dated June 22 and August 23, 2023. Per a review of available charting notes, over a period starting in May 2023 and ending with the resident’s discharge in January 2024, R1 sustained at least five separate fall incidents. A significant bruise on R1's buttocks was reported to the family and primary care provider on August 25, 2023 with no ability to clearly determine the origin of the bruise. On that day, R1 was sent to Mission Hospital via 911 for generalized weakness and low food/drink intake and diagnosed with acute kidney injury. No report on file submitted to the Orange County Regional Office. Another reported fall occurred on November 7, 2023, with facility staff indicating resident had lost their balance but were assessed to not present any injury or pain. Fall also not reported to the Department of Social Services per a review of Incident Reports on file. R1 sustained another fall on December 8, 2023 and was first transported via EMS to Hoag Hospital in Irvine before being transferred to Hoag Hospital Newport Beach at the neurosurgery department due to a suspicion of a subdural hematoma. A review of the resident records maintained at the facility also allowed LPA to corroborate that the responsible party for the resident had been contacted by the facility staff following the fall. A fax reporting the fall to the resident's physician was also located. Report states that EMS had initially informed the facility that the resident would be transported to Saddleback MemorialCare but was re-routed to Hoag Irvine for unknown reasons which appears to explain why R1’s responsible party had to actively attempt to locate the resident following admission. Finally, another fall incident, this time not resulting in significant injury also appeared to be documented on January 8, 2024 and reported to the resident's primary care physician and responsible party but not to the Department of Social Services. R1 were discharged to their authorized representative on January 9, 2024. Regarding the allegation that Staff did not provide adequate care and supervision to a resident, the following has been concluded: Despite multiple occurrences of fall incidents sustained by R1, the individual needs assessments conducted by facility staff on June 22 and August 23, 2023 fail to document the fact that the resident was at risk for falls. Furthermore, the evolution of R1’s Mild Cognitive Impairment to a documented diagnosis of dementia was not apparent in the physician until after the resident was hospitalized, in spite of signs and incidents occurring in the months leading to the emergency hospitalization. Continued on LIC9099-C Regarding the allegation that Staff did not properly report incidents involving a resident, the following has been concluded: No reports were made to the Orange County Regional Office during any of the documented fall or hospitalization incidents sustained by R1 in 2023 and 2024. As a result, both allegations are found to be Substantiated, meaning that the preponderance of the evidence standard has been met. Two deficiencies to Title 22 requirements are being cited on an attached form LIC9099-D . An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Mar 25, 2026 · control 22-AS-20240322140918

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(b) · Plan of correction due date: Apr 1, 2026

Per CCR 87463(b), “the reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition”. This requirement is not met as evidenced by: Based on records reviewed, R1 was never assessed to be a fall risk in spite of multiple occurrences of falls between May 2023 and January 2024, at least one of which resulted in an injury. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Mar 25, 2026

Plan of correction: Licensee agrees to review section cited and submit proof before the plan of corrections due date.

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

Per CCR, “Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency (…) within seven days of the occurrence of any of the events specified in (A) through (D) below. (D) Any incident which threatens the welfare, safety or health of any resident (…)” This requirement was not met as evidenced by: Multiple fall incidents including instances that resulted in injury and/or hospitalization were not reported to the Department. This constitutes a potentialthe state’s words, verbatim · CDSS document, Mar 25, 2026

Plan of correction: Licensee agrees to review reporting requirements and submit proof before the plan of corrections due date. risk to the health, safety and personal rights of individuals in care.

Type of visit: Required - 1 Year

On March 11, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Georgianna Mendez was present and assisted on today's visit. LPA observed that Georgianna Mendez has a valid Administrator certificate which expires on December 12, 2027. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for two hundred and twenty five residents, all of which can be non-ambulatory, twenty can be bedridden, and has a hospice waiver for thirty. The facility is a two building which consist of assisted living and memory care. Their are resident apartments in both areas, which have bathrooms located in suite. The facility also consist of common areas such as dining rooms in both the assisted living and memory care, activity areas, a commercial kitchen, staff offices, a salon, laundry rooms, a medication room, and a physical fitness center. LPA conducted a tour of the interior portions of the facility. On today's visit, there are ninety six residents in care. LPA observed residents eating lunch in the dining room. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected ten resident bedrooms located throughout the facility and observed them to be free of hazards. LPA observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA tested the call buttons in resident bedrooms and they tested operational. LPA inspected the resident bathrooms in the apartments inspected and observed them to be clean. LPA observed resident bathrooms to be equipped with grab bars and nonskid floor mats. Faucets and toilets were operational. Hot water temperature measured between 105.6 and 118.5 degrees Fahrenheit. LPA inspected the facility kitchen area and observed it be clean. LPA observed the facility to have a minimum two day perishable and seven day non-perishable food supply on hand. CONTINUED ON 809-C During a tour of the kitchen, LPA observed one staff preparing food without a hairnet. The staff advised LPA that they did not have any hairnets and that they had to be ordered. LPA observed the facility has a three day emergency food and water supply on hand. LPA observed multiple fire extinguishers to be mounted in the wall across the facility. All fire extinguishers were observed to be charged and serviced as of August 12, 2025. LPA observed that the facility had their most recent Fire Inspection conducted on August 22, 2025. LPA observed that the facility fire sprinklers and smoke detectors tested operational during the inspection. LPA observed the facility conducted their last emergency disaster drill on December 11, 2025. LPA observed the centrally stored medication to be kept in locked medicine carts located throughout the facility. LPA observed first aid kits to be stored in the medication room and they had all the required components. LPA observed all the facility's chemicals and toxins to be stored in a locked storage rooms. LPAnconducted a tour of the exterior portions of the facility. LPA observed the facility has outdoor areas for both assisted living and memory care. LPA observed the exterior to be free of obstructions and hazards. LPA observed shaded outdoor seating areas with furniture for resident use. LPA tested the delayed egress doors located on the exterior portions. One delayed egress door in the memory care portion was non-operational at time of visit. LPA reviewed ten resident files. LPA observed the Reappraisals on file for Resident #2 (R2), Resident #6 (R6), and Resident #7 (R7) were outdated and need to be updated. LPA reviewed residents' medication and medication administration records. LPA observed the facility did not have one medication for Resident #11 (R11) present at the facility, despite R11 having an active order for the medication. LPA observed the facility did not have three medications for Resident #12 (R12) present at the facility, despite R12 having active orders. LPA reviewed ten staff files. LPA observed that Staff #1 (S1) did not have any annual training on file for the year of 2025. LPA observed that Staff #11 (S11), Staff #12 (S12), Staff #13 (S13). Staff #14 (S14), Staff #15 (S15), and Staff #16 (S16), were not criminal background cleared or associated to the facility. Based on the observations made during today's visit, deficiencies are being cited on the attached LIC809-D pages. Civil penalties will also be assessed in the amount of $3,000.00 for criminal background clearance. An exit interview was conducted with Executive Director Georgianna Mendez. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Mar 11, 2026

Allegation investigated: Facility did not notify responsible party of change of condition for resident Staff mismanaged residents medication. Staff did not ensure resident is provided an adequate amount of water.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the five allegations listed above. LPA was greeted and granted entry by front desk after stating the purpose of the visit. Executive Director Georgianna Mendez was present on the premises and assisted with the visit after being presented with the allegations under review. The initial complaint investigation visit was conducted on February 24, 2022. During the visit, licensing staff requested and obtained resident R1's Medication Administration Records for the months of December 2021 and January 2022 as well as R1's charting notes for the same period. A follow-up visit took place on April 21, 2022 and involved multiple open complaints at the time. LPA conducted additional staff and resident interviews and obtained additional documentation. Hospital records for R1 were also obtained and reviewed during the investigation. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099-A Regarding the allegation that Resident not administered medication as prescribed, the following has been concluded: Resident R1 was briefly hospitalized at Providence Mission Hospital on January 20, 2022. Per the hospital report reviewed, R1 had been seen by their primary care provider in the weeks prior and prescribed a course of antibiotics for a urinary tract infection, which is alleged to not have been provided adequately to R1 by facility staff. Per a review of R1's hospital records, it was confirmed via testing that the infection treated had been resolved at the time of the admission to the emergency department for weakness and dehydration. A review of the Medication Administration Records provided additionally corroborates the medication being dispensed adequately. Regarding the allegation that Staff disposed residents medication, the following has been concluded: Upon R1's passing on February 8, 2022, facility staff proceeded to destroy the resident's medication as mandated by Section 87465(i) of the California Code of Regulations stating that "Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record". The record in question was provided during the investigation and added to the investigation file. Based on the evidence gathered, both allegations are determined to be Unfounded, meaning that the allegations are false, could not have happened and/or are without a reasonable basis. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC9099 Regarding the allegation that Facility did not notify responsible party of change of condition for resident, the following has been concluded: R1 was seen by their primary care provider in early January 2022 following the occurrence of a urinary tract infection with the knowledge of R1's attorney-in-fact. Identically, the hospitalization report dated January 20, 2022 shows that the attorney-in-fact and responsible party was informed of the call to the paramedics due to the resident's lethargic state. The admission on hospice care was initiated the same day with full knowledge of the responsible party. Charting notes following R1's readmission at the facility show multiple contacts with R1's family. Regarding the allegation that Staff mismanaged residents medication, the following has been concluded: It was alleged that after R1 was placed on medication management by facility staff after being assessed to no longer being able to handle their own medication in their physician report reviewed, some PRN medication (nitroglycerin prescribed as needed for R1's heart condition) had been left unaccounted for and accessible to the resident. Aside from one witness statement obtained during the investigation, no evidence of the presence of accessible prescription medication was provided to licensing staff. Regarding the allegation that Staff did not ensure resident is provided an adequate amount of water, the following has been concluded: Upon being admitted to the Emergency Department at Providence Mission Hospital on January 20, 2022, R1 was diagnosed with acute kidney injury secondary to dehydration and provided with two liters of intravenous liquids. Per the hospital report reviewed, R1 was alert and oriented at the time and was not documented as having any form of severe cognitive impairment. The hospital physician noted that R1 had been refusing to eat and drink in the days prior to the call to the paramedics. Based on the evidence gathered, the three allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Jan 27, 2026 · control 22-AS-20220217161044

Allegation investigated: Facility staff did not notice a change in the resident's condition Facility staff did not dispense resident's medication as prescribed

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the eight allegations listed and to deliver findings to the licensee. LPA was greeted and granted entry by the front desk staff after introducing himself and stating the purpose of the visit. Executive Director Georgianna Mendez was present on the premises and assisted with the visit after being presented with the allegations under review. The initial complaint investigation visit was conducted by licensing staff on August 27, 2021. During this visit, LPA spoke with Healthcare Director at the time Tracii Brown as well as obtained documentation such as medication administration record, admission agreement, and physician report for resident R1. Additional staff interviews were conducted over the course of the investigation. A follow-up visit was conducted on August 31, 2022. During this visit, LPA requested a facility staff roster and conducted seven staff interviews. CONTINUED ON FORM LIC9099-C Substantiated CONTINUED FROM FORM LIC9099-A During the August 2022 visit, licensing staff requested the laundry log for resident R1. A copy of the billed laundry service was provided during the visit. Regarding the allegation that Facility staff did not notify resident's authorized representative of a change in the resident's condition, the following has been concluded: Based on interviews and records reviewed during the investigation, no evidence was found that facility staff had knowledge of a change in R1's dental health prior to multiple broken teeth were found by R1's dentist on June 21, 2021 and surgically extracted on June 29, 2021. The dental care was scheduled and arranged by R1's responsible party, therefore the responsible party gained knowledge of the condition before facility staff did. Regarding the allegation that Facility staff did not ensure that resident had clean clothing, the following has been concluded: a laundry log and billing record for R1 shows 22 individual occurrences of laundry services being provided and billed to the resident's responsible party between the resident's admission in March 2020 and the resident's passing in January 2022. Interviews with facility housekeeping staff determined that initial clarification of the distinction between the linen service and personal laundry had been discussed with R1's family and that the resident regularly declined the service being provided on scheduled laundry days as R1 had already chosen to handle laundry themselves. Regarding the allegation that Resident was given a medical test without a doctor's order, the following has been concluded: the allegation was filed with the Department while the Coronavirus Disease 2019 (Covid-19) State Of Emergency had been declared. As part of the emergency declaration, facilities were operating under a waiver authorizing the use of PCR or antigen testing by facility staff for screening and isolation purposes. Additionally, R1's consent for emergency medical treatment LIC627 was signed by R1's responsible party in June 2019 and copied for the investigation file. No individual doctor's orders were required for testing at the time of the complaint. Regarding the allegation that Facility did not allow resident to use the pharmacy of their choice, the following has been concluded: Based on interviews conducted with staff, it was determined that residents are being provided the option to utilize the facility's preferred pharmacy provider but that individual choice to go through a different provider was possible as well. CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C Per a review of R1's resident records, medication orders dated April 18, 2020 made after the resident was admitted in 2019 show that prescription orders were sent to a CVS location in Orange rather than Guardian which was the preferred provider at the time, thus corroborating that the resident was free to go through a different pharmacy. Regarding the allegation that Facility is charging resident for services that are not in the Admissions Agreement, the following has been concluded: During the investigation of complaint reference 22-AS-20220211164547, the allegation that staff overcharged resident R1 was substantiated after it was determined that tray service had been charged in spit of a temporary suspension due to the coronavirus pandemic. However, the services for which charges have been disputed such as tray service and personal laundry were verified to be listed on Appendix C of the facility's admission agreement. Regarding the allegation that Facility staff is misappropriating facility funds, the following has been concluded: Following a change of facility management, records for the acquisition of religious decorations affixed to each resident's door could not be obtained. However, no actual evidence of misappropriation was provided during the complaint's investigation to corroborate the allegation. As a result, all six allegations mentioned above are determined to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. CONTINUED FROM FORM LIC9099 Regarding the allegation that Facility staff did not notice a change in the residents condition, the following has been concluded: Based on a review of medical records and charting notes, it is confirmed that upon admission R1 was on a regular diet. No issues with the resident dental health are documented in R1's charting notes prior to four broken teeth being extracted in June 2021, after which R1 was moved to a soft mechanical diet. It is therefore confirmed that the change in the resident's dental condition was not observed by staff in a timely manner. Regarding the allegation that Facility staff did not dispense resident's medication as prescribed, the following has already been concluded as part of the investigation of complaint "A review of the records and interviews concluded that the condition of Resident 1 (R1) was re-assessed by their primary care physician to have evolved to require assistance in the time period between yearly evaluations dated June 20, 2019 and August 20, 2020. The initial report indicates that the resident is noted as being able to self-administer their medication without supervision. The following physician report indicates however that the resident is no longer able to self-administer without supervision. Despite this change in condition, the resident was not transitioned to medication management status by the facility and formally assisted by facility staff until December 11, 2021 as documented in staff interviews as well as in printouts from the Medication Administration Records provided by the facility. (...) These elements confirm that the resident was left to manage her own medication with no formal assistance by the facility for a period of 16 months after a transition to Medication Management was ordered by the physician". A deficiency for the same resident and circumstances was already cited on January 18, 2023 and is therefore not issued a second time. Based on the evidence gathered during the investigation, the two allegations listed above are deemed to be substantiated, meaning that the preponderance of evidence standard has been met. One cited deficiency per Title 22 Division 6 of the California Code of Regulations is detailed in the attached form LIC9099-D. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.the state’s words, verbatim · CDSS document, Jan 21, 2026 · control 22-AS-20210819153706

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jan 22, 2026

Per CCR87477 Observation of the resident: "The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs." This requirement is not met as evidenced by the fact that R1's four broken teeth went unnoticed until they were diagnosed during a dentist visit organized by R1's responsible party. This constitutes a potential risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Jan 21, 2026

Plan of correction: Once the four teeth were extracted, R1's assessment was updated to reflect the need for a mechanical soft diet. Defiency cleared during the present visit.

Allegation investigated: Facility does not implement adequate activities for residents in care

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegation listed above and delivering findings. LPA was greeted and granted entry by Executive Director Georgianna Mendez after stating the purpose of the visit. The initial complaint investigation visit took place on June 16, 2025.During the visit, LPA conducted three staff interviews. The activities program for the present week was obtained along with the current bus schedule as well as activities listing posted in multiple locations throughout the facility. A tour of the physical plant was also conducted with the Activities Director. Staff communications both internally as well as with some of the residents' families were also provided via email during the visit. A follow-up visit was conducted on July 22, 2025. LPA conducted or attempted 10 resident interviews and one staff interview. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 During the visit, LPA observed assisted living and Sage unit residents participating in a scheduled game of Bingo in Sage, as well as observed musical entertainment offered in Assisted Living. LPA also observed residents attending chair yoga in the gym. Additional witness interviews were conducted during the investigation. Regarding the allegation that Facility does not implement adequate activities for residents in care, the following has been concluded: Based on observation, records reviewed and interviews with witnesses, staff and residents, it was determined that a variety of activities were being offered to facility residents with efforts being made to adapt the offering to the needs and wishes of residents. Activities materials and supplies are on hand. There is one full-time activities staff present as well as additional staff identified more specifically to provide activities to the residents of the Sage and memory care units. As a result, there is insufficient evidence to demonstrate that the activities offered are inadequate. The allegation is therefore found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 22-AS-20250609113755

Allegation investigated: Staff are not providing adequate care and supervision to the residents Staff did not accord resident's with dignity

On July 22, 2025, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the four allegations listed above. LPA was greeted and granted entry by Executive Director Erin Palposi after explaining the purpose of the visit. The initial complaint investigation visit was conducted on February 17, 2022. During thre visit, LPA requested and obtained the resident care plan and admission agreement for resident R1, as well as the staff work schedules for the week of 01/24/2022 to 01/30/2022. Copies of the shift reports have also been obtained along for the period being investigated. A resident interview with R1 was also conducted. A follow-up visit took place on April 21, 2022. LPA was able to obtain documentation of attendance for the most recent all-staff meeting during which pendant activation training was provided during the facility updates, as well as the complete log for all pendant pushes and pull-cord activations in the facility along with location and response time. CONTINUED ON FORM LIC9099-C Substantiated CONTINUED FROM FORM LIC9099-A Additional witness interviews were conducted during the investigation. Regarding the allegation that Facility failed to ensure oxygen tanks were in working order, the following has been concluded: Witness and resident interviews conducted evidenced that the equipment used by R1 for supplemental oxygen was functioning correctly. However, due to poor vision documented in R1's assessment and evidenced in interviews, R1 would occasionally require staff assistance to operate her small oxygen tank, with occasional excessive waiting times. Issues with oxygen seem to have been solved by the provision of a concentrator. Based on the evidence gathered, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of this report was provided to facility representative. CONTINUED FROM FORM LIC9099-A Additional witness interviews were conducted during the investigation. Regarding the allegation that Residents alerts are not operating while in care, the following has been concluded: Licensing staff conducted multiple visits during which the facility's call system was observed to be in operation. Staff and resident interviews conducted during the investigation did not evidence any period of time during which the call system was not in operation. Additionally, the vendor for the facility provided records of all pendant and pull cords activations for the period of January 2022 corresponding to the allegation being made. A review of the records provided confirmed the statements made indicating an absence of technical issues with the call system. As a result, the allegation is found to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC9099 Additional witness interviews were conducted during the investigation. Regarding the allegation that Staff are not providing adequate care and supervision to the residents, the following has been concluded: Based on interviews conducted and records reviewed, it was confirmed that on January 28, 2022 at approximately 10:30pm, staff was alerted by another resident's family of an ongoing episode. Staff notes from facility LVN Tiffany Kennebrew are reviewed as follows "Care staff and another resident's family reported that resident was yelling out in hallway. Nurse on duty checked on resident and noted that the resident had increased agitation and oxygen level was below 90%. 911 called to evaluate resident. EMT's reported that resident was having [signs and symptoms] of panic attack [due to] not being able to work portable oxygen machine. Resident refused hospital transport and EMT's educated resident on how to properly work machine. [Daughter] Sherri notified and this nurse asked [daughter] to look into getting a concentrator for ease of use of oxygen therapy". Due to the resident's assessed vision issues and response delay, facility staff appears to have failed to meet the requirement to ensure the resident could safely operate their oxygen equipment. Regarding the allegation that Staff did not accord resident's with dignity, the following has been concluded: A review of the facility's records for pendant pushes on January 28, 2022 demonstrates that the initial activation made by R1 is timestamped as follows: "1/28/2022 21:49 [...] Alpers, Helene (lives in Apt 255) 244-2033 from Receiver by 154, [...] Announced 9 times. Healthcare Wristlet 150CD responded at 10:32 p (43 mins)." As R1 was experiencing difficulty in operating their oxygen equipment, R1 had to wait 43 minutes to receive assistance from staff and was observed being agitated in the hallway. As a result, both allegations are found to be Substantiated, meaning that the preponderance of evidence standard has been met. An exit interview was conducted and a copy of this report along with appeal rights was provided and left at the facility.the state’s words, verbatim · CDSS document, Jul 22, 2025 · control 22-AS-20220209101001

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87618(b)(1) · Plan of correction due date: Aug 15, 2025

Per CCR Section 87618(b)(1) on Oxygen Administration: "the licensee shall be responsible for the following: Monitoring of the resident's ongoing ability to operate the equipment in accordance with the physician's orders". This requirement was not met as evidenced by: Based on interviews and record reviews, facility staff did not monitor R1's ability to operate their oxygen equipment and failed to provide timely assistance. This constitutes a potential risk to the health, safety and personal rights of residents in care,the state’s words, verbatim · CDSS document, Jul 22, 2025

Plan of correction: Licensee to audit residents using oxygen equipment to ensure their ability to operate in accordance to physician orders. Proof of review to be submitted before the plan of corrections due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jul 31, 2025

Per CCR 878464(f)(1) on Basic Services: "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 is not met as evidenced by: Based on records reviewed and interviews conducted, instances of excessive response times were recorded for resident R1 over the reviewed period of January 2022.This constitutes a potential risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Jul 22, 2025

Plan of correction: Licensee received a similar citation for more recent instances of the same allegations. Current corrections will be reviewed in order to clear this additional deficiency based on older circumstances.

Allegation investigated: Staff does not ensure residents are spoken to in an appropriate manner Staff does not respond to call signal system for residents in a timely manner

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegations listed above. LPA was greeted and granted entry by front desk staff after stating the purpose of the visit. Executive Director Erin Palposi was present on the premises and assisted with the visit. An initial investigation visit took place on January 17, 2025. During the visit, licensing staff requested and obtained the facility's resident census, staff roster as well as care assignments for staff for Friday January 17, 2025. Five (5) staff interviews and four (4) resident interviews were conducted during the present visit. Resident records requested for a total of seven (7) residents. Follow-up interviews conducted on March 18, 2025 during the investigation of a different complaint. Additional staff and resident interviews conducted during the annual visit on May 14, 2025. CONTINUED ON FORM LIC9099-C Substantiated CONTINUED FROM FORM LIC9099-A During the follow-up to the investigation, LPA was provided with a recording of all activity related to pendant pushes for the period of December 23, 2024 until January 22, 2025. Staff records for staff member S1 were also provided during the March 18, 2025 visit and added to the investigation file. Regarding the allegation that Staff handle residents in a rough manner, the following has been concluded: Complaints of inappropriate staff interactions made during staff and resident interviews mostly described verbal interactions on behalf of staff member S1 rather than inappropriate or rough direct physical handling. No specific instances of rough handling were evidenced during the investigation. No specific acts were described by interviewees either during the present investigation. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided. CONTINUED FROM FORM LIC9099 During the follow-up to the investigation, LPA was provided with a recording of all activity related to pendant pushes for the period of December 23, 2024 until January 22, 2025. Staff records for staff member S1 were also provided during the March 18, 2025 visit and added to the investigation file. Regarding the allegation that Staff does not ensure residents are spoken to in an appropriate manner, the following has been concluded: Multiple staff members interviewed during the investigation related incidents they witnessed and/or reported to their supervisor involving inappropriate behavior from facility staff S1. Incidents described included ignoring calls for assistance, being short with residents requesting assistance, throwing medication across a table. Per a review of S1 staff files and interviews conducted, S1 was hired at the facility in 2011 and was terminated prior to the March 18 visit taking place due to inappropriate behavior. Regarding the allegation that Staff does not respond to call signal system for residents in a timely manner, the following has been concluded: Based on resident interviews and a review of pendant pushes over a period of 30-days, it was established that approximately three daily occurrences of pendant pushes requiring upwards of forty-five minutes to be addressed were recorded. While a wide majority of pendant pushes are addressed timely, these occurrences demonstrate that timely response is not guaranteed. As a result, both allegations are found to be Substantiated, meaning that the preponderance of evidence standard has been met. Two type B deficiencies are being cited per California Code of Regulations Title 22. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 22, 2025 · control 22-AS-20250108143658

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jun 20, 2025

Per CCR (a) 87468.1(a)(1) defining Personal Rights: "Residents in all RCFE 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 staff and resident interviews conducted, staff member S1 was responsible of inappropriate behavior towards multiple residents. This constitutes a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Staff member S1 was terminated with cause by licensee on March 11, 2025 as confirmed by interviews and a review of staff files. No other staff evidenced to have interacted inappropriately with residents during the investigation. Deficiency cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 878464(f)(1) · Plan of correction due date: Jun 20, 2025

Per CCR 878464(f)(1) on Basic Services: "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 is not met as evidenced by: Based on records reviewed and interviews conducted, multiple instances of excessive response times were recorded.This constitutes a potential risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Licensee will utilize the newly hired Wellness Director to keep track and audit pendant pushes regularly, conduct bi-monthly in-service training and identify root causes of excessive wait times. Documentation of the corrections to be provided to LPA before the plan of corrections due date.

Allegation investigated: Staff do not respond to resident’s calls for assistance in a timely manner

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegations listed above. LPA was greeted and granted entry by front desk staff after stating the purpose of the visit. Executive Director Erin Palposi was present on the premises and assisted with the visit. The initial complaint investigation visit took place on March 18, 2025. During the visit, LPA requested and obtained the current facility census. LPA additionally requested resident records for five residents of the Sage unit as well as the log for pendant pushes recorded in the facility for the past 30 days. Three resident interviews along with one staff interview were also conducted during the visit. Additional staff and resident interviews conducted during the annual visit on May 14, 2025. During the follow-up to the investigation, LPA reviewed logged pendant pushes for 30 days ending in March 2025. CONTINUED ON FORM LIC9099-C Substantiated CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff do not respond to resident’s calls for assistance in a timely manner, the following has been concluded: Based on interviews conducted and records reviewed there are on average 116 pushes per day. When ruling out pushes related to low battery levels in the pendant, there remains 139 pushes for which the response time between call system activation and endorsement of the call by staff exceeded 45 minutes, hence over four daily occurrences of excessive wait for the residents in care. As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. One type B deficiency is being cited per California Code of Regulations Title 22 and an immediate civil penalty for a repeat violation is being assessed. An exit interview was conducted and a copy of this report and appeal rights were provided. CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff do not ensure that resident is provided with meals in a timely manner, the following has been concluded: Earlier in 2025, the facility terminated its contract with its former dining vendor for financial reasons. A higher number of staff than anticipated left to remain with the vendor at the time. Facility staff supplemented the missing dining staff with additional shifts from caregiving staff which ensured continuity of service throughout the transition. Based on staff and resident interviews, the transitional period is now almost over and routine service has resumed. Throughout the period however, no incidents involving meals not being served timely were evidenced during interviews conducted. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, May 22, 2025 · control 22-AS-20250312161858

From the deficiency page — Deficiency type: Type B · Section cited: CCR 878464(f)(1) · Plan of correction due date: Jun 20, 2025

Per CCR 878464(f)(1) on Basic Services: "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 is not met as evidenced by: Based on records reviewed and interviews conducted, multiple instances of excessive response times were recorded.This constitutes a potential risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Licensee will utilize the newly hired Wellness Director to keep track and audit pendant pushes regularly, conduct bi-monthly in-service training and identify root causes of excessive wait times. Documentation of the corrections to be provided to LPA before the plan of corrections due date. CIVIL PENALTY FOR REPEAT VIOLATION ASSESSED

Allegation investigated: Staff are not implementing proper infection control practices at the facility Staff was not sufficient in numbers to meet the needs of residents in care

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the two allegations listed above. LPA was greeted and granted entry by front desk staff after introducing himself and stating the purpose of the visit. Business Office Director Danielle Brahier was present to assist with the visit while Executive Director Erin Palposi was notified via phone and could not be present in person. An initial investigation visit took was conducted by licensing staff on February 7, 2025. During visit, LPA conducted interviews with residents and staff. LPA also reviewed and obtained copies of facility and resident records. Additional staff and resident interviews were conducted during the present visit. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff are not implementing proper infection control practices at the facility, the following has been concluded: LPA reviewed the facility's Infection Control Plan as well as documentation of the precaution measures taken during the occurrence of a COVID and norovirus outbreaks in January 2025. Precautions and hygiene measures appeared sufficient. Staff and resident interviews did not evidence any concerns regarding precautions taken. Additionally, adequate reporting and follow-up with the Orange County Public Health Department were evidenced. Regarding the allegation that Staff was not sufficient in numbers to meet the needs of residents in care, the following has been concluded: Care staff assignments for the month of January 2025 were provided and reviewed along with assignments for the day of the present visit. Per their review, it was determined that a minimum of six staff per shift for the Sage and Memory Care units combined and six staff per shift for the rest of the Assisted Living residents were scheduled and present. The overnight shift is covered by an average of six to eight staff total, half for Sage and Memory care and half for the Assisted Living. Staff and residents interviewed did not evidence needs that were not met as a result of insufficient staffing. As a result, both allegations listed above are found to be Unsubstantiated, meaning that while the alleged incidents may have occurred, or the concerns may be valid, there is not a preponderance of evidence to prove that the alleged violations took place. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, May 14, 2025 · control 22-AS-20250130132925

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by front desk staff after introducing himself and stating the purpose of the visit. Business Office Director Danielle Brahier was present to assist with the visit while Executive Director Erin Palposi was notified via phone and could not be present in person. LPA reviewed the facility's resident census, staff roster, Emergency and Disaster Plan, Infection Control Plan, staff schedules. There are 118 residents in care, nine of which are residing in memory care. There are eight residents receiving hospice care at the time of the visit. A sample of eight staff records and twelve resident records were requested and reviewed during the visit. Resident records appear complete and meet the regulatory requirements. During the visit, LPA provided a consultation on updated requirements for yearly medical assessment for all residents regardless of a dementia diagnosis. All staff members listed on the facility's roster form are verified to be background cleared and associated to the facility at the time of the visit. CPR training is current for all staff members reviewed. Proof of initial and annual training also provided and reviewed. The facility is a two-story building divided in three sections (Assisted Living, Sage Living and Memory Care) around a central courtyard with a secure swimming pool. LPA accompanied by facility staff conducted a tour of the interior and exterior of the physical plant. A total of 11 occupied units were inspected during the tour Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Bathrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats or floor materials. Hot water was measured within the required range in six distinct locations throughout the facility. CONTINUED ON FORM LIC809-C CONTINUED FROM FORM LIC809 The fire panel and sprinkler inspection reports were reviewed during the visit and did not evidence any issues with the fire safety systems at this time. Wall-mounted fire extinguishers are observed throughout the premises and appear to have received adequate maintenance per the tags attached. Auditory exit alarms were operational. The facility utilizes delayed egress for the memory care. Use of delayed egress approved by the Fire Marshall upon delivery of the fire clearance. Evacuation chairs confirmed to be in place at the top of staircases. Fire and evacuation drills are conducted as evidenced by the training records provided. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to residents in the memory care. LPA reviewed the physician orders and medication on hand in one of the facility's medication cart for a total of eleven residents with no discrepancies observed. For the exterior portion, facility has several patio furniture sets with umbrellas for shade and the grounds and routes of egress were free of tripping hazards. No deficiencies are cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along was left at the facility.the state’s words, verbatim · CDSS document, May 14, 2025

Allegation investigated: Staff did not ensure medications were dispensed as prescribed Staff did not ensure resident records were properly managed Staff did not ensure reporting requirements were followed

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above. LPA met with Executive Director (ED) Erin Palposi. Regarding allegation Staff did not ensure medications were dispensed as prescribed, the following was revealed: During the course of the investigation, LPA reviewed Medication Administrator Records (MARs) for select residents and interviewed four staff. LPA observed discrepancies in six of nine resident records. A review of Resident 1’s (R1’s) prescribed medication indicated six routine medications were not administered on March 29th, 30th, and 31st of 2025, as they were still present in the prescribed bubble pack issued by the pharmacy. Upon review of MAR, it was observed it had not been signed by staff to indicate why it had not been administered or otherwise. A review of R2’s medication indicated one routine medication was not administered on March 29th, 2025, as it was still present in the prescribed bubble pack issued by the pharmacy. Upon review of MAR, it was observed it had not been signed by staff to indicate why it had not been administered or otherwise. (Cont. LIC9099-C) Substantiated A review of R3’s prescribed medication revealed two routine medications for April 10th and 11th of 2025 were no longer present in the prescription bubble pack issued by the pharmacy. During their interview, S1 stated they were aware the medication for the two days was missing, but stated they were unsure of how the discrepancy occurred. Three additional staff interviewed denied any knowledge of the missing medication. A review of R4’s prescribed medication indicated two routine medications for April 10th and 11th of 2025 were no longer present in the prescribed bubble pack issued by the pharmacy. During their interview, S1 stated they were aware the medication for the two days was missing, but stated they were unsure of how the discrepancy occurred. Three additional staff interviewed denied any knowledge of the missing medication. A review of R5’s medication indicated three routine medications were not administered on March 30th, 2025, as they were still present in the prescription bubble pack issued by the pharmacy. Upon review of MAR, it was observed it had not been signed by staff to indicate why it had not been administered or otherwise. A review of R6’s medication indicated one routine medication was not administered on March 23rd, 24th, and 29th of 2025, as it was still present in the prescribed bubble pack issued by the pharmacy. Upon review of MAR, it was observed it had been signed by staff to indicate it had been administered despite it still being present in the prescription bubble pack. Regarding allegation Staff did not ensure resident records were properly managed, the following was reviewed: Upon review of MARs for select residents, LPA observed discrepancies in four of nine resident records. Upon review of R1’s MAR, it was observed it had not been signed by staff on March 29th, 30th, and 31st of 2025 to indicate why six routine medications had not been administered or otherwise. Upon review of R2’s MAR, it was observed it had not been signed by staff on March 29th, 2025 to indicate why one routine had not been administered or otherwise. Upon review of R5’s MAR, it was observed it had not been signed by staff on March 30th, 2025 to indicate why three routine had not been administered or otherwise. Upon review of R6’s MAR, it was observed one routine medication had been signed by staff on March 23rd, 24th, and 29th of 2025 to indicate it had been administered despite it still being present in the prescription bubble pack. Regarding allegation Staff did not ensure reporting requirements were followed: LPA conducted a record review of Incident Reports (LIC624) submitted by the facility to Community Care Licensing (CCL) and did not observe any incidents reports for the medication errors listed above. During today’s visit, LPA was provided with an incident report for medication errors. (Cont. LIC9099-C) Based on staff interviews and records review, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was provided at the end today's inspection.the state’s words, verbatim · CDSS document, Apr 9, 2025 · control 22-AS-20250402151546

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.2(c) · Plan of correction due date: Apr 10, 2025

"Care and supervision" means the facility assumes responsibility for... ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety or welfare would be endangered. This requirement is not met as evidenced by: Based on staff interviews and records review, the licensee did not comply with the section cited above as residents' medications are not being dispensed as prescribed, which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 9, 2025

Plan of correction: ED stated staff training on medication management will be conducted and a copy provided to LPA with proof via email by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Apr 23, 2025

(a) The licensee shall ensure that a separate, complete, and current record is maintained... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as four of nine resident MARs were observed to be incomplete, which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 9, 2025

Plan of correction: ED stated residents' MARs will be updated to reflect correct information regarding medication administration and copy provided to LPA via email by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Apr 23, 2025

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as an incident report was not submitted within seven days following a medication error which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 9, 2025

Plan of correction: ED stated they will provide LPA with a written plan of action to ensure compliance with regulation via email by POC date.

Allegation investigated: Staff are not allowing resident to leave the facility Staff are not allowing resident to take a shower Staff threaten resident in care Staff is forcing resident to obtain psychiatric treatment without cause

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced complaint visit to continue the investigation into the above allegations. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and residents. Regarding the allegations that staff are not allowing resident to leave the facility, staff are not allowing resident to take a shower, staff threaten resident in care and staff is forcing resident to obtain psychiatric treatment without cause, the investigation revealed the following: Per interview conducted with Resident 1 (R1), facility does allow resident to leave the facility. Physician report dated 03/18/2021 indicated resident is able to leave the facility unassisted. Resident denied being refused showers and facility charge form shows resident received stand by assistance 7 days a week for showering. Per interview with resident, resident denied any staff threatening her at the facility. Resident had obtained psychiatric care multiple times while admitted to facility and denied being forced to obtain treatment and confirmed needing said treatment. CONTINUED ON LIC 9099 C DATED 01/31/2025. Unfounded Five out of five residents interviewed state satisfaction with facility and indicate staff is good to them. Based on interviews conducted and records reviewed, the allegations are deemed UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jan 31, 2025 · control 22-AS-20211008154417

Allegation investigated: The facility staff did not check on resident to turn regularly resulting in deep tissue wound on leg The facility staff handled the resident in a rough manner The facility failed to provide food for the resident in a timely manner The resident was not given medications as prescribed The resident was not receiving laundry services as agreed The resident was found saturated in urine and feces on multiple occasions due to facility not providing incontinent care The facility did not send the correct health agent's information to the hospital with the resident resulting in the resident's health agent not being informed of the situation or make decisions on resident's behalf

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced complaint visit to continue to the investigation into the above allegations. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as facility notes. Regarding the allegations that facility staff did not check on resident to turn regularly resulting in deep tissue wound on leg, the facility staff handled the resident in a rough manner, the facility failed to provide food for the resident in a timely manner, the resident was not given medications as prescribed, the resident was not receiving laundry services as agreed, the resident was found saturated in urine and feces on multiple occasions due to facility not providing incontinent care and the facility did not send the correct health agent's information to the hospital with the resident resulting in the resident's health agent not being informed of the situation or make decisions on resident's behalf, the investigation revealed the following: Resident 1 (R1) was diagnosed with stage 4 ovarian cancer. CONTINUED ON LIC 9099C DATED 01/31/2025 Unsubstantiated Facility nurse's notes indicate resident was admitted to hospice care 01/18/2021 and started receiving wound care daily on 02/07/2021 until end of life 02/22/2021. Three out of three staff state resident was being repositioned every 2 hours due to the wound. Resident started receiving the fentanyl patch effective 02/05/2021. Facility notes indicate resident was receiving the patch by hospice nurse. Facility staff state resident was receiving meals delivered to the resident's room due to covid pre-cautions and all residents received meals. Facility does not have copies of meal checklists from 2021. Interview with housekeeper familiar with resident indicated all laundry services were performed for the resident. Three out of three staff state incontinence care is provided every 2 hours and deny resident was left soiled. All staff interviewed state resident's needs were being met and all deny any staff being rough with any resident. Five out of five residents state satisfaction with facility and indicate staff is good to them. Facility does not have Durable Power of Attorney (DPOA) paperwork on file however R1's face sheet designates a DPOA and a medical proxy to two different individuals. Based on interviews conducted and records reviewed, LPA is unable to corroborate the allegations. Therefore the allegations are deemed UNSUBSTANTIATED, meaning although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jan 31, 2025 · control 22-AS-20210302151348

Allegation investigated: Facility is refusing to accept the resident back to the facility.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering the findings of the investigation into the allegation listed above. LPA was greeted and granted entry by front desk staff after introducing himself and stating the reason for the visit. Administrator Erin Palposi was present and assisted with the visit after being informed of the allegation. The initial complaint investigation visit took place on March 28, 2024. During the visit, LPA requested and obtained records maintained at the facility for resident R1. An interview with facility staff regarding R1's current hospitalization was also conducted. R1 was stated to be undergoing psychiatric evaluation prior to organizing her readmission at the facility. An additional witness interview was conducted via telephone. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 During the follow-up investigation visit, two staff interviews were conducted along with an interview of resident R1. Additional resident records were requested and obtained after a new physician report and resident assessments had been conducted. Regarding the allegation that the Facility is refusing to accept the resident back to the facility, the following has been concluded: Resident R1 was sent out to receive a psychiatric evaluation following an incident involving aggression towards a staff member on March 21, 2024. The resident was still hospitalized during the initial complaint investigation visit. Multiple interviews with facility staff confirmed that no eviction was notified to the resident or their responsible party and that the goal of the hospital stay was to ensure the safety of both staff and resident upon readmission. Treatment adjustments were conducted and the resident was admitted back to the facility's memory care unit in April 2024. No new incidents have been reported by facility staff since the readmission took place. There is no additional evidence that a plan to not readmit the resident was ever in place and the resident has successfully returned to the facility. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director Erin Palposi and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Jul 1, 2024 · control 22-AS-20240327152419

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by front desk staff after introducing himself and stating the purpose of the visit. Interim Executive Director Marjorie Silberman was notified and assisted with the visit. LPA reviewed the facility's resident census, staff roster, Emergency and Disaster Plan, Infection Control Plan, staff schedules. A sample of ten staff records and ten resident records were reviewed during the visit. The facility is a two-story building divided in three sections (Assisted Living, Sage Living and Memory Care) around a central courtyard with a secure swimming pool. LPA accompanied by administrator conducted a tour of the interior and exterior of the physical plant. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide, and auditory exit alarms were operational. Bathrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats. Hot water was measured at 115 degrees Fahrenheit in memory care and 109 degrees Fahrenheit in Sage living resident bathrooms. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to residents in care. LPA reviewed the physician orders and contents of one of the facility's medication cart. Fire extinguishers were mounted and charged. For the exterior portion, facility has several patio furniture sets with umbrellas for shade and the grounds and routes of egress were free of tripping hazards. One type B deficiency was cited per Title 22 Division 6 of the California Code of Regulations and three Technical Assistance Advisory Notes were provided. An exit interview was conducted and a copy of this report along with appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Mar 28, 2024

Allegation investigated: Staff left resident in soiled clothing for an extended period of time causing a rash. Resident not administered medication as prescribed. Staff does not provide adequate food service for residents.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation into the allegation listed above. LPA was greeted and granted entry by facility administrator Georgianna Mendez after stating the purpose of the visit and listing the allegations. An initial complaint investigation visit was conducted on June 6, 2022. LPA reviewed records for four residents in care and conducted staff and resident interviews were also conducted. LPA additionally reviewed menus and requested a report of the call system activations. During the present follow-up visit, LPA requested and obtained the facility's resident census as well as the lists of residents on medication management, receiving incontinence supplies from the facility as well as the tray service records for the week leading to the present visit. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 LPA then attempted or conducted resident interviews with six randomly selected residents who are both indicated to be on Medication Management and receiving incontinence supplies from the facility directly. Additional resident interviews had been conducted during prior facility visits investigating other complaints filed against the facility. Regarding the allegation that Staff left resident in soiled clothing for an extended period of time causing a rash, the following has been concluded: Evidence gathered through record reviewed and interviews conducted was insufficient to corroborate that any individual residents were left in soiled clothing with obtaining timely assistance from staff. Regarding the allegation Resident not administered medication as prescribed, the following has been concluded: Based on a review of electronic medication administration records as well as multiple interviews with residents on Medication Management conducted on November 11, 2022 and November 28, 2023, no specific instance of residents identified as requiring medication assistance per their assessment not receiving their medication in accordance to the prescription orders on file with the facility. Regarding the allegation that Staff does not provide adequate food service for residents, the following has been concluded: Based on interviews conducted with residents and staff, no evidence of meals not being provided was found. LPA was able to verify the facility's system established to keep track of specific tray service requests and observed that all meals on the dates reviewed were accounted for. Additionally, no complaints regarding food not being served altogether were made during the resident interviews conducted. As a result, all three allegations listed above are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Nov 28, 2023 · control 22-AS-20220531121519

Allegation investigated: Facility did not provide resident's records to resident's responsible party.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation into the allegation listed above. LPA was greeted and granted entry by facility administrator Georgianna Mendez after stating the purpose of the visit and listing the allegations. The initial complaint investigation visit was conducted on February 17, 2022. During the visit, LPA requested and obtained the resident care plan for resident R1, as well as the staff work schedules for the week of 01/24/2022 to 01/30/2022. The requested admission agreement for R1 could not be located at the time of the visit, resulting in a deficiency that was cited at the time. A follow-up visit was held on April 21, 2022 and one interview was conducted with the facility accountant at that time. CONTINUED ON FORM LIC9099-C Unfounded CONTINUED FROM FORM LIC9099-A Regarding the allegation that Facility overcharged resident., the following has been concluded: Based on a review of email exchanges between facility staff and R1's authorized representatives along with staff interviews and a review of R1's billing records for the period of November 2021 until February 2022, it was confirmed that additional charges for tray service were charged to the resident in spite of the ongoing policy to waive the fees in question during the occurrence of outbreaks of COVID-19 as well as during periods of illness experienced by the resident. The allegation is therefore found to be Substantiated, meaning that the preponderance of evidence standard has been met. A Type B citation is issued on the attached form LIC9099-D An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative. CONTINUED FROM FORM LIC9099 Regarding the allegation that Facility did not provide resident's records to resident's responsible party, the following has been concluded. At the time of the follow-up visit conducted on April 21, 2022, the authorized representative for R1 had been provided with the requested documentation as confirmed by a review of written exchanges along with interviews with involved parties. Therefore the allegation is found to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. The complaint allegation is therefore dismissed.the state’s words, verbatim · CDSS document, Nov 28, 2023 · control 22-AS-20220211164547

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(3)(B)(2) · Plan of correction due date: Dec 28, 2023

The California Code of Regulations Section 87507(g)(3)(B)(2) states that: "A separate charge (...) may be assessed only if that charge is included in and authorized by the admission agreement." In the absence of the agreement and due to the COVID waivers in place at the time, the separate (...) charges for tray services should not have been assessed as observed on billing documents. This constitute a potential risk for the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Nov 28, 2023

Plan of correction: Licensee will re-initiate the dialogue with R1's family to resolve any potential excess paid. Proof of the discussion will be provided to LPA by the Plan of Corrections due date.