High Desert Haven

Type of visit: Office

On 08/12/2026, an informal meeting was held at the Fresno Regional Office. The purpose of this meeting was to discuss recently identified issues/concerns associated with the operation of the facility. The informal meeting process was explained during this meeting. The following were in attendance at this meeting: Licensee, Baruch (Ben) Berkowitz via telephone Administrator, Brittany Kavanaugh Assistant Administrator, Taylor Wagner Licensing Program Manager I, Alexandria Walton Licensing Program Manager I, Shawna Doucette Licensing Program Analyst (LPA), Brianna Miranda During this meeting the following items were discussed: · Fire Clearance & Facility Sketch · Administrator Qualifications · Admission Agreement · Personal Rights · Medications During this meeting, the Licensee agrees to provide a written statement regarding updating the clinical platform and notifications regarding maintenance issues. No deficiencies issued. Exit interview conducted. A copy of this report was discussed and provided to Administrator Brittany Kavanaugh, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Aug 12, 2026

Type of visit: Case Management - Other

On July 23, 2026 Licensing Program Analysts (LPAs) B. Miranda & M. Vega arrived at the facility unannounced. LPAs conducted a case management visit to cite deficiencies found while conducting an investigation for complaint # 24-AS-20260717154025. LPAs met with Administrator, Brittany Kavanaugh. LPAs reviewed R1’s centrally stored medication log to not be properly completed. Nicotine 21 MG/24 HR Patch, RX 07803603, Expiration date 10/3/2026, Date Filled (blank), Date Start 7/1/2026; Spiriva Respimat 2.5 mcg, RX 07803598, Expiration date 10/3/2026, Date Filled (blank), Date Start 7/1/2026; Diclofenac Sodium 1% gel, RX 07803597, Expiration date 10/3/2026, Date Filled (blank), Date Start 7/1/2026. Centrally stored medication log is not being properly maintained. During the visit on July 18, 2026 LPAs observed R1 & R2 to be in room 152. Room 152 is listed as having a bedroom and living room. R1 was placed in the living room, and would have to cross into R2’s bedroom in order to used the bathroom. LPA spoke with S1 and asked if the fire clearance for the facility had been updated with the Fire Dept, S1 stated yes but was not able to provide verification during the visit of July 18, 2026. LPA asked S1 if Licensing had been informed, S1 stated they believed so. LPA checked the facility’s records and there was no notification from the facility regarding the new fire clearance for changes made. Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Administrator, Brittany Kavanaugh.the state’s words, verbatim · CDSS document, Jul 23, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87202(a) · Plan of correction due date: Jul 31, 2026

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by: Based on observation, interview, and record review the facility did not comply with the regulation listed abovedue to facility not notifying Licensing of changes made to fire clearance, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2026

Plan of correction: Administartor will provide proper documentation to Licensing by POC due date regarding changes in fire clearance.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(a)(2(C) · Plan of correction due date: Jul 31, 2026

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement is not met as evidenced by: Based on observation, interview, and record, the facility did not comply with the regulation listed above due to R1 having to go into R2's bedroom to access the bathroom, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2026

Plan of correction: Administrator has moved R1 and R2 to indiviual rooms. This was verified during today's visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(6) · Plan of correction due date: Jul 31, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observation, interview, and record, the facility did not comply with the regulation listed above due to R1's centerally stored medication log to not be completed correctly, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2026

Plan of correction: Administrator will conduct new staff training on meds and ceneranllt stored log. Statement will be provided indicating when training will be completed.

Type of visit: Case Management - Other

On July 18, 2026 Licensing Program Analyst (LPAs) B. Miranda & M. Vega arrived at the facility unannounced to investigate and unrelated complaint #24-AS-20260717154025. While at the facility LPAs observed medication in R1's night stand and cleaning products under the bathroom sink (pictures taken). R1's most recent physician report date June 8, 2026 states they are not able to administer their own medications and R1's at risk for disinfectants, cleaning solutions, sharp objects, etc. In the night stand LPAs observed scissors, lighter, Ibuprofen 200 mg, and Diclofenac Sodium 1%. Under the bathroom skin LPA observed Comet with bleach, dish soap, and disinfecting spray. Citations were issued under California Title 22. Exit interview was conducted and a copy of this report LIC809, LIC809D, LIC421FC and appeal rights were provided to Assistant Administrator Taylor Lloyd and Administrator Brittany Kavanaugh via phone.the state’s words, verbatim · CDSS document, Jul 18, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jul 21, 2026

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in LPAs observed cleaning supplies, scissors, and lighter unlocked and accessible to facility residents, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 18, 2026

Plan of correction: Administrator will reach out to doctor regarding physican report for R1. Inservice will be conducted. A statement will be provided to the Dept by POC due date explaining action to be taken to correct deficiency.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Jul 21, 2026

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above due to R1 having Ibuprofen 200 mg, and Diclofenac Sodium 1% in night stand unlocked and accessible, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 18, 2026

Plan of correction: Administrator will conduct in-service with staff. A statement will be provided to the Dept by POC due date explaining action to be taken to correct deficiency.

Type of visit: Case Management - Incident

On July 15, 2026 Licensing Program Analysts (LPAs) B. Miranda and M. Vega arrived at the facility unannounced to conduct a case management visit. LPAs met with Taylor Lloyd Assistant Administrator & Wellness Care Director Elizabeth Vasku. LPAs explained the reason for the visit. The Dept received a report indicating on June 21, 2026 R1 had a gash on their leg. While speaking with Elizabeth is was discovered R1 had a skin tear which had some bleeding but was tended to by staff. During today's PAs did not observe "oxygen in use" signs being posted. The facility previously report R2 had left the facility unassisted. LPA reviewed R2's physician report and IPP. Physician's report indicates supervision recommended for R2. IPP also indicates R2 will walk away if upset or routine is interrupted. Citations were issued under California Title 22. Exit interview was conducted and a copy of this report LIC809 was provided to Assistant Administrator Taylor Lloyd.the state’s words, verbatim · CDSS document, Jul 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2 · Plan of correction due date: Jul 16, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on observation, interview, and record, the facility did not comply with the regulation listed above, which poses an Immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: Facility will provide a statement regarding R2's needs being met and the possiblity of reassessing R2.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87618(b)(3)(B) · Plan of correction due date: Jul 20, 2026

87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (B) "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas. This requirement is not met as evidenced by: Based on observation, interview, and record, the facility did not comply with the regulation listed above, which poses an Immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: During the visit facility posted a "No smoking- Oxygen in use" sign posted. POC cleared today.

Allegation investigated: Facility charged resident's bank account without authorization

On 5/13/26 Licensing Program Analysts (LPAs) M. Medina and M. Garza arrived at the facility for an unannounced complaint visit. LPAs met with Activities Director, Taylor Lloyd and Wellness Director, Elizabeth Vasku to conduct visit. During visit LPAs conducted interviews, requested and received the following documents for R1: medical assessment, pre-admission appraisal, admission agreement, ALW paperwork and ACH paperwork. During interviews, R1 indicated that they received their bank statement and saw charges from the facility and notified the bank of possible unauthorized charges. R1 stated that they then reviewed their bank statements from previous months and realized the charges are for their responsible portion of monthly rent. R1 stated they provided a voided check to facility during admission to facility. R1 also acknowledged that the initials on the Authorization Agreement for Direct Deposit Payments form for ACH debits was their signature. This Department has found that the above allegation is UNFOUNDED, meaning they were false, could not have happened, and/or were without reasonable basis. We have therefore dismissed the complaint. Exit interview completed with Activities Director, Taylor Lloyd and Administrator, Brittany Kavanaugh via telephone. A copy of this report provided via e-mail for facility records. Unfoundedthe state’s words, verbatim · CDSS document, May 13, 2026 · control 24-AS-20260512144042

Allegation investigated: Staff are not addressing pests at facility Staff did not prevent resident from smoking while residents use oxygen Staff do not maintain facility in good repair Staff do not ensure that residents care needs are met Facility smells malodorous

On 5/13/26 Licensing Program Analysts (LPAs) M. Medina and M. Garza arrived at the facility for an unannounced complaint visit. LPAs met with Activities Director, Taylor Lloyd who contacted, Administrator Brittany Kavanaugh by telephone to advise of complaint visit. Wellness Director, Elizabeth Vasku arrived a short time later ton also conduct visit. Residents were observed in common areas and in their rooms. During subsequent visit, LPAs conducted additional interviews. Facility provided documentation showing pest control provided treatment in two phases, conducted 2 weeks apart for resident 1's (R1s) room. Facility provided documentation of occurrences with R1 for smoking in unauthorized areas. R1 was provided redirection to the designated smoking area and resident signed acknowledgement for resident smoking policy. Facility had an incident on 4/16/26, for a smell of burning in facility. The fire department was dispatched and facility was cleared with no fires. Invoice provided from the electrician observed no electrical problems at the time of visit. On 4/22/2026, facility ordered 10 additional pendants and 2 walkie-talkies for residents in care. During interviews, it was stated that staff 1 was terminated in February 2026 after complaints of care from both residents and staff. Although the allegation may or may not have occurred the preponderance of evidence standard has not been met per California Code of Regulations, Title 22. The allegations listed above are UNSUBSTANTIATED. Nothe state’s words, verbatim · CDSS document, May 13, 2026 · control 24-AS-20260421083453

Type of visit: Case Management - Incident

On 05/13/2026, Licensing Program Analysts (LPAs) M. Medina and M. Garza arrived at the facility for an unannounced case management visit. LPAs met with Wellness Director, Elizabeth Vasku to conduct facility tour of the facility inside and out. A health and safety check was conducted on residents in care. Residents observed in common areas and in rooms. LPAs spoke with Administrator, Brittany Kavanaugh via telephone to advise of case management. This case management is being conducted for an incident report received by the Department on 4/15/26 for an incident occurring with R1 on 4/13/26. Incident report indicated that R1 was complaining of chest pain and EMS was contacted. Upon arrival R1 declined EMS services and transport to hospital. During visit LPAs requested and reviewed documentation (Resident roster, medical assessment for R1, preplacement appraisal, emergency and identification information, admission agreement, and discharge paperwork) and completed interviews. Review of medical assessments for R1 indicates that R1 has a pacemaker. Interview with R1's grandson indicated R1 is independent and able to make medical decision for themselves and sees their cardiologist regularly (every 3 months). No deficiencies cited during this visit. Exit interview completed with Wellness Director, Elizabeth, Activities Director, Taylor and Administrator, Brittany via telephone.the state’s words, verbatim · CDSS document, May 13, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Sarah Hurt and Brianna Miranda conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator, Brittany Kavanaugh, Continual Administrator's Certification expires 02/22/2028. There are currently 73 residents who reside at this home and there is 6 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The facility performs disaster drills as required. Water temperature was tested in multiple rooms to be between 105 and 120 degrees. First Aid kit is on site and complete. LPA's reviewed a sample of staff and residents files, facility Plan of Operation, Emergency Disaster Plan, and Infection Control Plan. Resident 1 and Resident 2's pre admission appraisal is not completed. Resident 3's updated Needs and Services appraisal (in house form RCFE Home Health & Hospice Service Plan) is not complete. Resident 4's Admission agreement does not document accurate amount to be paid, admission agreement amount is $4,800, and charged amount is $1,000. Resident 5 is on a special diet that is not being followed. Resident 5 has over the counter medications accessible in bedroom despite Physician's Report documenting they are not able to manage own medications, Resident 5's medications are not documented correctly on Centrally stored medication record. Continued... LPA's observed toxins and cleaning supplies unlocked and accessible to residents. LPA's advised all facility wings should have carbon monoxide detectors. The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing. Exit interview conducted with Administrator, Brittany Kavanaugh, and copy of report left at facilitythe state’s words, verbatim · CDSS document, May 12, 2026

The state marks this report as 9 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Facility washers and dryers are in disrepair

On 4/29/2026, Licensing Program Analysts (LPAs) M. Medina and M. Garza conducted an unannounced subsequent complaint visit to facility. LPAs introduced themselves and stated purpose of visit, LPAs met with Administrator, Brittany Kavanaugh via telephone and gave permission for visit to be completed with Wellness Director, Elizabeth Vasku. During visits LPAs toured facility, completed interviews, requested and reviewed documentation (staff schedules, resident roster, invoices, staff training records). During facility tour on 4/11/2026, LPAs observed the following in the assisted living building, 2 washers and 1 dryer that were inoperable, in the memory care building of the facility 1 washer and 1 dryer that were inoperable. The allegation listed above have met the preponderance of evidence standard per California Code of Regulations, Title 22. The allegations are SUBSTANTIATED.the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 24-AS-20260403093954

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 29, 2026

a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. ***This was not met as evidenced by: During facility tour on 4/11/2026, LPAs observed the following in the assisted living building, 2 washers and 1 dryer that were inoperable, in the memory care building of the facility 1 washer and 1 dryer that were inoperable.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: Facility purchased 3 washers and 2 dryers, invoices provided to LPA during complaint visit. DEFICIENCY CLEARED AT TIME OF VISIT

Type of visit: Case Management - Other

On 3/21/2026, Licensing Program Analysts (LPAs) M, Medina and M. Garza conducted a Case Management visit due to observation made during complaint (# 24-AS-20260227130105) visit on this date. During facility tour, it was observed that resident R1 had oxygen in use. LPAs observed that there was no "No Smoking-Oxygen in Use" sign posted and there were 2 oxygen tanks that were not secured. During visit, oxygen signs were posted outside residents room and agency was notified to provide oxygen stands to secure oxygen. Technical Violation provided. Exit interview conducted and a copy of this report was emailed to facility for their records.the state’s words, verbatim · CDSS document, Mar 21, 2026

Allegation investigated: Staff does not ensure to provide resident's transportation to doctor appointments Staff does not follow activities calendar

Licensing Program Analyst Shawna Doucette met with Administrator at the Fresno Regional Office to deliver findings. LPA met with Administrator Brittany Kavanaugh and Wellness Director Elizabeth Vasku and Licensee Ben Berkowitz (Teams). During the course of the investigation, LPA conducted a facility tour, reviewed records, and conducted interviews. Interviews conducted with residents revealed that R1 missed two doctor appointments between August and September 2025 and R2 missed a doctor appointment on 11/19/2025 due to transportation staff not being present. Upon review of S1’s personnel file, LPA discovered that S1 was released from employment due to S1’s failure to transport residents to their scheduled appointments. Substantiated Upon review of the activity calendar, it was found that the facility scheduled activities seven days a week. Consistent statements from residents in care revealed that the facility does not have enough staff to ensure activities are provided on the weekends. Residents are attempting to attend scheduled activities, however upon arrival there are no staff present to assist with activities. Records review revealed that the facility did not provide staff assistance to the Activities Director in order ensure activities are provided as scheduled. Based on interviews and records review, the preponderance of evidence standard has been met, therefore allegations: Staff does not ensure to provide resident's transportation to doctor appointments, and Staff does not follow activities calendar, are found to be SUBSTANTIATED. Deficiencies are being cited in accordance with California Code of Regulations, Title 22, Division 6 on the attached 9099D. Exit interview conducted and a plan of correction was developed and reviewed with Administrator. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 27, 2026 · control 24-AS-20251110182020

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2) · Plan of correction due date: Feb 13, 2026

87465 Incidental Medical and Dental (a) A plan for incidental medical and dental care shall be developed by each facility…(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service… This requirement was not met as evidenced by: Based on interviews and records review, the Licensee did not comply with section 87465 when R1 and R2 missed scheduled appointments due to staff being unable to transport R1 and R2 to their appointments, which is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 27, 2026

Plan of correction: Licensee agrees to submit a written statement on how this regulation will be met by the facility by POC due date 02/13/26

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(f) · Plan of correction due date: Feb 13, 2026

87219 Planned Activities(f) In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities… This requirement was not met as evidenced by: Based on interviews and records review, the Licensee did not comply with section 87219 when the Activities Director was not given staff assistance to ensure activities were provided as scheduled, when the Activities Director was not available, which is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 27, 2026

Plan of correction: Licensee agrees to submit a written statement on how the facility will meet this regulation by POC due date 02/13/26.

Allegation investigated: Licensee did not follow proper eviction procedures for resident.

Licensing Program Analyst Shawna Doucette met with Administrator at the Fresno Regional Office to deliver findings. LPA met with Administrator Brittany Kavanaugh and Wellness Director Elizabeth Vasku. Licensee Ben Berkowitz. During the course of the investigation, LPA conducted interviews and reviewed records. Upon review of records, it was found that R1 was admitted to the hospital on 11/4/2025 due to behavioral issues at the facility. Hospital staff attempted to discharge R1 to the facility on the same date, however discharge was unsuccessful. Hospital staff contacted the Ombudsman, who assisted R1 in returning to the facility. R1 was discharged and transferred back to the facility on 11/21/2025. Based on interviews conducted and records review, the allegation: Licensee did not follow proper eviction procedures for resident is UNSUBSTANTIATED. 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. No deficiencies issued. Exit interview conducted. A copy of this report was discussed and provided to Administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 27, 2026 · control 24-AS-20251112135800

Type of visit: Office

On 01/27/26, a meeting was held at the request of the Licensee in the Fresno Regional Office. The purpose of the meeting was to discuss recently identified issues/concerns associated with the operation of the facility. The meeting process was explained during this meeting. The following were in attendance at this meeting: Licensee, Ben Berkowitz Licensee Representative, Brittany Kavanaugh Staff, Elizabeth Vasku Regional Manager, Brenda White Licensing Program Manager I, Alexandria Walton Licensing Program Manager 1, Sergiy Pidgirny Licensing Program Analyst, Shawna Doucette Licensing Program Analyst, Brianna Miranda Legal Representative, Joel Goldman Legal Representative, Joyce O'Brien · During this meeting the following topics were discussed: · Administrator Qualifications · Staffing Procedures Licensee agreed to submit a written statement detailing how the Administrator will bring the facility in compliance. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 27, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Shawna Doucette met with at the Fresno Regional Office. LPA met with Administrator Brittany Kavanaugh and Wellness Director Elizabeth Vasku. Licensee Ben Berkowitz. During the course of the investigation for complaint number 24-AS-20251112135800, LPA discovered the following: Interviews conducted with staff revealed that on 11/4/2025, R1 began demonstrating challenging behaviors and was transported to a hospital by Facility Staff. Hospital records indicate that R1 was to be discharged back to the facility on 11/4/2025. It was found during interviews that R1 requested to return to the facility, however facility staff refused to accept R1 back from the hospital due to R1’s complaints about the facility and challenging behaviors. Medical records confirmed that the facility refused to accept R1 back from the hospital from 11/4/2025 -11/21/2025. With the assistance from the Ombudsman and hospital staff, R1 returned to the facility on 11/21/2025 via hospital transportation. Upon arrival, facility staff stated they accepted the resident back to the facility. A deficiency is being cited in accordance with California Code of Regulations, Title 22, Division 6 on the attached 809D. Exit interview conducted and a plan of correction was developed and reviewed. A copy of this report and appeal rights were discussed and provided to Administrator.the state’s words, verbatim · CDSS document, Jan 27, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(20) · Plan of correction due date: Mar 13, 2026

Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (20)To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents for reasons other than those permitted by state law or regulations and shall comply with all eviction and relocation protections for residents… This requirement was not met as evidenced by: Based on interviews and record review, the Licensee did not comply with section 87468.2 when facility staff transferred R1 to a hospital and refused to accept R1 back once R1 was discharged, which is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 27, 2026

Plan of correction: Licensee agrees to conduct a staff training on resident's personal rights by POC due date 02/13/26.

Allegation investigated: Staff are transporting residents while under the influence, impairing their ability to provide adequate care and supervision

Licensing Program Analysts (LPA)'s Shawna Doucette and Brianna Miranda arrived at the facility unannounced to deliver complaint findings. LPA's met with Staff Danielle Mouw. LPA's interviewed staff and residents. Interviews revealed that staff have never seen S1 using drugs or alcohol at the facility. It is unknown if staff are transporting residents while under the influence, impairing the ability to provide adequate care and supervision. Based on interviews, Although the allegations listed may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. A copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 10, 2025 · control 24-AS-20251119091440

Type of visit: Case Management - Deficiencies

On 12/10/2025 Licensing Program Analysts (LPAs) B. Miranda & S. Doucette arrived at the facility unannounced to conduct a case management visits to issue citations for deficiencies found while investigating complaint #24-AS-20251112135800. LPAs introduced themselves and explained the reason for the visit. LPAs met with Danielle Mouw and explained the reason for the visit. LPAs reviewed R1's records and observed R1's admission agreement was signed on 10/29/2025, and an incomplete pre-admission appraisal. On 11/4/2025 R1 was taken to the hospital. Staff Danielle Mouw stated the facility was not able to handle R1's behaviors and R1 was being aggressive towards staff. R1 returned to the facility on 11/21/25 and a reappraisal was not completed for R1's change in condition indicating wound care and a puree diet. On 11/18/2025 LPA verbally requested a printout of resident's call button log and via email on 11/25/2025. No records have been provided until today during an unannounced visit. The delay in providing required documents impedes the process of a complaint. Deficiencies were cited under Title 22. Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Danielle Mouw.the state’s words, verbatim · CDSS document, Dec 10, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c)(1)(A) · Plan of correction due date: Dec 22, 2025

87457 Pre-Admission Appraisal (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall document, at a minimum: (A) An evaluation of the prospective resident's functional capabilities, mental condition, and social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factor. This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not properly conduct a pre-admission appraisal which poses a potential Health and Safety or Personal Rights risk to persons in care. R1 was taken to the hospital due to behaviors and staff not being able to meet R1's needs. R1 does not have a completed pre-admission appraisal and did not have a re-appraisal completed when R1 returned to the facility.the state’s words, verbatim · CDSS document, Dec 10, 2025

Plan of correction: Licensee will conduct staff training to cover pre-apprasials and reapprasials. Verification of training and topics coveed will be provided to LPA by POC date 12/22/2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(d) · Plan of correction due date: Dec 22, 2025

87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not provide the records being requested in a timely manner which poses a potential Health and Safety or Personal Rights risk to persons in care. On 11/18/2025 LPA verbally requested a printout of resident's call button log and via email on 11/25/2025. Verification was not provided until 12/10/2025.the state’s words, verbatim · CDSS document, Dec 10, 2025

Plan of correction: Licensee is able to use flash drive to download documents and print when needed.

Type of visit: Case Management - Other

On 11/18/25 Licensing Program Analyst (LPA) B. Miranda & S. Doucette arrived to the facility unannounced to conduct a complaint investigation. LPAs met with Wellness Director Elizabeth Vasku and Assist Executive Direct Danielle Mouw. During the investigation the following deficiencies were observed. LPAs observed an unoccupied housekeeping cart with cleaning supplies and chemicals accessible to residents in care. LPAs observed housekeeping staff to be in a residents room. LPAs also reviewed a rent increase notice with no proper date. This does not show the proper 90-day notice was given. Technical violation was issued requesting a packet be provided for a qualified administrator. Packet is due in the office on 11/25/25 by 12:00 p.m. Deficiencies were cited under Title 22. Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Assist Executive Direct Danielle Mouw.the state’s words, verbatim · CDSS document, Nov 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Nov 19, 2025

87309 Storage Space and Access (a) Except as specified in subsection, the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the regulation listed above, which poses an immediate Health and Safety or Personal Rights risk to persons in care. LPA observed an unoccupied housekeeping cart with chemicals and cleaning supplies being accessible to residents in care.the state’s words, verbatim · CDSS document, Nov 18, 2025

Plan of correction: Licensee will talk with housekeeping and metal lock boxes will be bought to store chemicals and cleaning supplies on cart.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655 · Plan of correction due date: Nov 25, 2025

§1569.655 Increase in fee rates for elderly residents; 90 days’ written notice standing amount of reasons for increase; application of section (a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 90 days’ prior written notice to the residents or the residents’ representatives setting forth the amount of the increase and the reason or reasons for the increase, including a description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident. This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the regulation listed above, which poses a potential Health and Safety, Personal Rights risk to persons in care. LPA observed a letter informing residents on a rent increase which did not have a date, providing 90-day notice.the state’s words, verbatim · CDSS document, Nov 18, 2025

Plan of correction: Facility will give residents letters that the inital increase notice is not valid. Proper notice will be provided and given to resdients with correct dates. Facility will provide LPA copies of the letters.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct a Case Management for an incident that occurred on 08/29/25 and for late reporting for incidents. LPA met with Administrator Danielle Mouw and Wellness Director Elizabeth Vasku. LPA interviewed Administrator and Wellness Director. Incidents that occurred on 09/6/25 and 09/07/25 were not reported until 09/19/25. Based on interviews, the incident that occurred on 8/29/25, R1 attempted to go into R2's room, which upset R2. R1 was found with a laceration on R1's head. Staff did not witness the altercation due to staff not being in assigned area. R1 was found by the medication technician to have a laceration on R1's head. R2 was still yelling at R1 at the time the medication technician observed R1's laceration. Medication Technician redirected R1 and R2 and called 911 for R1. R1 went to the hospital and was later returned to the facility. R1 had skin adhesive applied to close the wound. Prior to this incident R1 and R2 were having verbal altercations where staff were able to intervene. Refer to 809D. A copy of this report was provided with appeal rights and plans of corrections.the state’s words, verbatim · CDSS document, Oct 15, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Oct 16, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by Licensee did not ensure R1 was free from abuse due to R1 being hit by R2 causing R1 to be hospitalized, which poses an immediate health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2025

Plan of correction: Plan of Correction Licensee agrees to submit in writing a plan to ensure how this regulation will be met by POC due date 10/16/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Oct 16, 2025

87211 Reporting Requirements (a) 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 and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by Licensee did not submit incident reports timely. For example Licensee submitted incident reports that occurred on 09/6/25 and 09/7/25 on 09/19/25 which poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2025

Plan of correction: POC LIcensee agrees submit a plan in writing on how this regulation will be met by POC due date 10/16/25.

Type of visit: Office

On 08/19/2025, an informal meeting was held at the Fresno Regional Office. The purpose of the informal meeting was to discuss recently identified issues/concerns associated with the operation of the facility. The informal meeting process was explained during this meeting. The following were in attendance at this meeting: Licensee Representative, Brittany Kavanaugh Staff, Danielle Mouw Licensing Program Manager I, Alexandria Walton Licensing Program Analyst, Shawna Doucette During this meeting the following topics were discussed: · Administrator Qualifications · Staffing · Resident Records · Reporting Requirements During this meeting, the Licensee Representative and Staff were notified that the hospice wavier for the facility has been reduced to six residents due to non-compliance. TSP was discussed and offered. A referral will be made on their behalf. Licensee Representative was provided with all applicable regulations. A copy of this report was discussed and provided to the Licensee Representative.the state’s words, verbatim · CDSS document, Sep 4, 2025

Allegation investigated: Resident ingested another residents medication due to staff leaving medication accessible to other residents in care

Licensing Program Analysts (LPAs) Daiquiri Boyd and Shawna Doucette conducted the 10 Day complaint investigation visit to the facility. During the course of this complaint investigation visit, LPAs interviewed staff and obtained and/or reviewed resident and facility records. It was determined based on the Incident Report submitted by the facility and records review that the above allegation is SUBSTANTIATED. Facility staff left medication accessible, allowing a resident (R1) access to another residents (R2) medications, and as a result R1 then injested medication that was prescribed for R2, requiring medical attention for R1. Based on LPAs records review and submitted reports, 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. Substantiatedthe state’s words, verbatim · CDSS document, Sep 3, 2025 · control 24-AS-20250825180500

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 4, 2025

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: staff left medication accessible during medication administration and R1 then injesting R2's medications resulting in R1 needing medical attention; which poses an immediate risk to the health, safety, or personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Facility completed staff training on Medication Administration on 08/21/25. Proof of training was submitted to LPA Doucette on 9/3/25. POC cleared during visit.

Allegation investigated: Staff does not ensure resident is spoken to in an appropriate manner Staff do not ensure residents room is kept in clean sanitary conditions Staff does not ensure residents dietary plan is followed Staff does not ensure food being served is of good quality Staff does not ensure residents personal hygiene needs are being met Facility did not replace residents personal property due to being damaged

Licensing Program Analysts LPA’s Shawna Doucette and Daiquiri Boyd arrived at the facility unannounced to investigate and deliver complaint findings. LPA’s met with Wellness Director Elizabeth Vasku. LPA's reviewed records and conducted interviews. Regarding the allegation Staff does not ensure resident is spoken to in an appropriate manner Based on staff interviews and resident interviews there were no witnesses to staff speaking inappropriately to a resident. Regarding allegation Staff do not ensure residents room is kept in clean sanitary conditions. Based on facility tour, LPA's observed several resident rooms to be clean. Based on staff interviews R1 often refuses to allow staff to clean R1's room. Based on resident interviews staff are cleaning rooms frequently, as allowed by residents. Unsubstantiated Regarding the allegation Staff does not ensure residents dietary plan is followed Based on interviews and records review, R1's LIC 602 does not state R1 requires a special diet. Based on records review and interviews, R1 is provided a menu to list items R1 will eat and is provided alternative options. Regarding the allegation Staff does not ensure food being served is of good quality Based on resident interviews and observation residents are being served good quality food. LPA's arrived at the facility while the residents were eating lunch. LPA's observed residents to be eating fish and chips with coleslaw and a piece of cheesecake. Regarding the allegation Staff does not ensure residents personal hygiene needs are being met. Based on records review R1's LIC 602 states R1 requires assistance with personal hygiene. Based on staff and resident interviews, R1 often refuses assistance with personal hygiene needs. LPA was unable to determine if staff are not ensuring R1's personal hygiene needs are being met. Regarding the allegation Facility did not replace residents personal property due to being damaged. Based on interviews, it is undetermined whether or not personal property was damaged and needed to be replaced. Facility did not have a personal property list due to R1's representative refusing to provide information which was signed on the LIC Although the allegations listed may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. A copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 3, 2025 · control 24-AS-20250902145755

Allegation investigated: Staff neglect resulted in a resident sustaining multiple pressure injuries Staff do not meet the needs of residents diagnosed with a restricted health condition Staff do not provide adequate care and supervision of the residents Staff are not following proper reporting requirements Staff are mishandling the residents medications

Licensing Program Analysts LPA’s Shawna Doucette and Sarah Hurt arrived at the facility unannounced to investigate and deliver complaint findings. LPA’s met with Administrator Linda Poythress. LPA's conducted interviews and reviewed records. Regarding the allegation Staff neglect resulted in a resident sustaining multiple pressure injuries: Based on records review and interviews, during visit on 06/27/25 R7 did not have a Hospice Care Plan. LPA's Sarah Hurt and Shawna Doucette returned on 08/6/25 and R7 has a Hospice Care plan, which does not address the stage of R7's wound or that R7 has a wound and staff responsibilities. Hospice care plan states R7 needs to be turned/repostioned every 2 hours. Hospice Care Plan does not state staff were trained on repositioning/turning R7, however R7 is not bedridden. Staff interviews indicate R7 does have a wound. Substantiated Regarding the allegation Staff do not meet the needs of residents diagnosed with a restricted health condition: Based on interviews and records reviews, R2 does not have a Home Health Care Plan. Based on interviews Staff are draining catheter bag without training from Home Health. Staff are cleaning the insertion area of the catheter. Facility does not have a restricted health care plan for R8's restricted health condition or staff training. Regarding the allegation Staff do not provide adequate care and supervision of the residents: Based on records review and interview, facility staff did not respond to change feces soiled brief for R1 for several hours. After conducting staff interviews facility staff stated response time to call lights is 5 minutes. After review of records of call light system for June 18, 2025 to June 25, 2025 several were over 15 minutes to 1 hour and 45 minutes. Regarding the allegation Staff are not following proper reporting requirements. Resident 1, and resident 4 were not given prescribed medication for multiple days during the month of June 2025. Facility staff did not report the missed medication to Licensing as required. Regarding the allegation Staff are mishandling the residents medications. Resident 1 and Resident 4 missed multiple prescribed medications during the month of June 2025. No reason was documented as to why medications were not being administered to residents. R4 should have had a medication administered at 8 PM and did not get the medication until 10:19 PM. Based on records reviewed interviews and observation for the allegations preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. A copy of this report with plans of correction and appeal rights were provided. Regarding the allegation Staff do not provide transportation service for the residents. Based on interviews, R1 chose to lay on the floor and did not fall. R1 did not want to be transported. Regarding the allegation Staff denied a resident access to food. Based on staff interviews, and observation Resident R1 is being offered food daily. LPA’s interviewed three facility staff who all stated R1 is declining food and not currently eating regularly. Resident R1 is currently on hospice due to rapid health decline. LPA’s observed caregiver bringing dinner tray to Resident R1 during visit. Although the allegations listed may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. A copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 6, 2025 · control 24-AS-20250625124618

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 7, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met by R1 and R4 not receiving several medications in the month of June 2025, which poses and immediate health safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Plan of Correction: Licensee agrees to submit a plan indicating the date and source of medication training and submit by POC due date 08/07/25

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87609(4) · Plan of correction due date: Aug 7, 2025

(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s). THie requirement was not met as evidenced by Licensee did not have a Home Health Care Plan or staff training for R2's restricted health condition and straff are cleaning the insertion area of the restricted health condition and R8 does not have a restricted Health Care Plan for R8's restricted health condition, which poses an immediate health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: The Licensee agrees to submit a of a home health care plan for R8 due to R2 no longer residing at the facility by 08/7/25

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 6, 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 ection 1569.2(c). This requirement was not met as evidenced by: Licensee did not meet R1's inontinence needs and staff not responding to call lights within in a timely manner on several days in the month of June 2025 ranging from 15 minute to 1 hour 45 minutes which poses an immediate health safety and personal rights to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Licensee agrees to submit a written plan on how care and supervision needs will be met by POC due date 08/07/25

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(a) · Plan of correction due date: Aug 12, 2025

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident’s hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident’s or prospective resident’s Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s). This requirement was not met as evidenced by R7 not having a Hospice Care Plan indicating care needed which poses a potential health safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Plan Of Correction Licensee agrees to obtain a complete hospice care plan for R7 by POC due date 08/12/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: Aug 12, 2025

87211 Reporting Requirements (a) 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 and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by Licensee did not report R1 and R4's missed medications which poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Licensee agrees to submit in writing a plan on how this regulation will be met by POC due date 08/12/25

Type of visit: Case Management - Incident

Licensing Program Analysts LPA’s Shawna Doucette and Sarah Hurt arrived at the facility unannounced to conduct a Case Management visit. LPA’s met with Administrator Linda Poythress. On 7/31/2025, at approximately 9:00am, Resident 1 and Resident 2 were observed in a verbal altercation. As Staff went to redirect both residents, Resident 1 made physical contact with Resident 2. Resident 1 was observed falling backwards and landing on their rear. Resident 2 was immediately escorted away from the scene. Resident 1 stated their left hip and left leg were hurting. EMS was notified. POA, daughter of Resident 1, was notified. EMS transported Resident 1 to Ridgecrest Regional Hospital for further evaluation. Facility Wellness Director and facility Administrator Linda Poythress were notified. Based on the update from Ridgecrest Regional Hospital, Resident 1 was diagnosed with a broken hip and taken into surgery later in the day. No deficiencies cited. Please see complaint control #24-AS-20250625124618 as facility was cited on 08/06/2025 for substantiated allegation related to resident Care and Supervision. Exit interview conducted with Administrator Linda Poythress. A copy of this report along with appeals rights provided.the state’s words, verbatim · CDSS document, Aug 6, 2025

Allegation investigated: Staff did not ensure temperature of food served to resident was appropriate, resulting in resident sustaining multiple burns. Staff threatened resident.

Licensing Program Analysts (LPAs) Shawna Doucette and Daiquiri Boyd arrived at the facility 09/03/2025 to amend documents previously signed. Licensing Program Analysts LPA’s Shawna Doucette and Sarah Hurt arrived at the facility on 0716/2025 unannounced to deliver complaint findings. LPA’s met with Administrator Linda Poythress. LPA interviewed residents and staff. LPA reviewed medical records. Based on medical records review and interviews, it is undetermined whether staff did or did not ensure the food served to residents was at an appropriate temperature, resulting in resident sustaining multiple burns. Medical records did not indicate resident sustained any burns. Based on interviews, it is undetermined if staff threatened a resident. Through interviews conducted, LPA did not find any evidence of threatening statements being made to any residents. Unsubstantiated Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 16, 2025 · control 24-AS-20250620164716

Type of visit: Post Licensing

Licensing Program Analysts (LPA) Sarah Hurt and Shawna Doucette arrived for a post licensing inspection. LPA was met by Administrator Linda Pothyress. The facility currently has a census of 72 residents at the time of this inspection. A complete tour of the facility was done. Medications are properly stored and secured in a locked cabinet. Food supply was checked and a 2 day supply of perishable and 7 day supply of non-perishable was checked. Fire extinguisher/smoke detectors and buildings and grounds are checked and observed to be operational. LPA's reviewed facility Plan of Operation, Infection Control Plan, and Emergency Disaster Plan. A sample of resident's and staff's files were checked. Resident's files have signed Admission Agreements and Physicians reports. Staff are fingerprinted clear and associated and have current CPR. LPA's observed Resident 1 in room 111 has a folding lawn type chair in bedroom as furniture. LPA's observed Resident 2 has medications out and accessible despite Physicians report documenting they are not able to administer own medications. LPA's observed Resident 3 in room 147 sink faucet water temperature measured to be 130 degrees. Resident 4 does not have required hospice care plan. The following deficiencies are being cited for this visit. Exit interview conducted with Licensee Administrator Linda Pothyress, and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 16, 2025

Allegation investigated: Staff did not distribute resident's medication as prescribed Staff did not assist resident with showering Staff did not ensure that resident's incontinence care needs were met

Licensing Program Analysts (LPA) Sarah Hurt and Shawna Doucette conducted an unannounced facility visit to investigate the allegations listed above. LPA met with facility Administrator Linda Poythress, and explained the purpose of today's visit. Regarding the allegation Staff did not distribute resident's medication as prescribed. Resident 1 was not given several doses of their medications on Friday June 13, 2025. The facility staff stated there was a miscommunication upon admission with the facilities online medication tracking system causing Resident 1's missed medication doses. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Substantiated Regarding the allegation Staff did not assist resident with showering. Resident 1 was not showered after having a significant bowel movement which left them with fecal matter on their back, and backside. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Regarding the allegation Staff did not ensure that resident's incontinence care needs were met. Resident 1 was not assisted with toileting timely. Facility pendant alert system documents Resident 1 waiting more than 30 minutes at times for assistance. Based on interviews conducted, and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The following deficiencies are being cites Per title 22 Regulations. Exit interview conducted with Administrator Linda Poythress. A copy of this report provided along with appeals rights.the state’s words, verbatim · CDSS document, Jun 24, 2025 · control 24-AS-20250617153822

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a) · Plan of correction due date: Jun 25, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. The following requirement has not been met as evidenced by: Resident 1 was not given several doses of medication on 06/13/2024, which poses an immediate, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 24, 2025

Plan of correction: Administrator will conduct training with staff on resident medications upon admission and submit to LPA by POC date 06/25/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(a) · Plan of correction due date: Jul 9, 2025

87464 Basic Services (a) The services provided by the facility shall be conducted so as to continue and promote, to the extent possible, independence and self-direction for all persons accepted for care. Such persons shall be encouraged to participate as fully as their conditions permit in daily living activities both in the facility and in the community. The following requirement has not been met as evidenced by: Resident 1 was not showered after which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 24, 2025

Plan of correction: Administrator will conduct training with staff on Basic services of residents including bathing and submit to LPA by POC date of 07/09/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87265(a) · Plan of correction due date: Jul 2, 2025

87625 Managed Incontinence(a) The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition under the following circumstances: The following requirement has not been met as evidenced by: Resident 1 was not assisted timely with incontinent care, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 24, 2025

Plan of correction: Administrator will conduct training with staff on Incontinent care of residents including bathing and submit to LPA by POC date of 07/09/2025.

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) L. Xiong arrived to the facility announced to conduct the Pre-licensing inspection. LPA met with Administrator Linda Poythress. LPA toured facility. Common rooms have adequate furnishings and lighting. All of the resident bedrooms have required furnishings and adequate lighting. Hot water temperature in bathrooms measured at 115 degrees F. Medications will be kept in a locked inside the call room. First aid kit contains all the required items. Fire extinguishers present throughout facility and have a service date of 4/2024 and 10/24. Smoke detectors and carbon monoxide detector tested and are operational. Facility is also equipped with pull station and signal system. Outside of the facility toured. All fire exits open free of obstruction. Perimeter of facility is surrounded by a gate. Component III conducted during pre-licensing inspection. No deficiency observed during visit.the state’s words, verbatim · CDSS document, Apr 22, 2025