Highgate Senior Living-Temecula

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced annual required visit. Upon entry, LPA was greeted by Lyssa Irani, community resources manager, and informed them of the purpose of the visit. At the time of the visit, there were 35 staff members and 91 residents present. Facility Overview: The facility is a two story building with (88) bedrooms and (95) bathrooms. There are no swimming pool or known firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility has infection control plan in file. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. The facility has laundry facility operated by staff for the residents in care. Sharp and dangerous objects were securely locked and inaccessible to residents. LPA reviewed state fire marshal inspection report dated 03-25-2025 and observed that the facility passed the fire safety inspection. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. LIC809-C.... Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate. Record Review and Resident/Staff Files: LPA reviewed files for five (5) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Five (5) resident files were reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for five (5) residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 12-20-2025, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided.the state’s words, verbatim · CDSS document, Jan 26, 2026

Allegation investigated: Staff did not consult responsible party regarding a resident's care Staff do not distribute resident's medication as prescribed

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with Melissa Villafana and explained the reason for the visit. The investigation consisted of the following: On 11/22/22 LPA Nwogene conducted an initial complaint investigation visit. On 10/13/25 LPA contacted facility’s administrator and requested copies of resident #1(R1)’s physician’s report, needs and care plan, emergency and information sheet, vaccine records, facility’s mitigation plan and infection control plan. On 10/14/25 LPA Flores conducted interviews with 5 staff over the phone. On 10/16/25 LPA Flores conducted interviews with 8 residents and reviewed medication for 9 residents and collected the documents previously requested, admission agreement, medication records for August – November of 2022, and chart notes for September – November 2022 for R1. LPA delivered findings. (CONTINUED ON LIC 9099C) Substantiated The investigation revealed the following: Regarding allegation: Staff did not consult responsible party regarding a resident's care. It is alleged resident’s responsible party was not contact before giving R1 a vaccination dosage during facility’s vaccination clinic day. Interviews with residents revealed 5 out of 8 residents stated facility staff either contact responsible party before medical decisions or believe that it will happen. 1 out of 8 residents did not know if the facility staff will contact their responsible party. 1 out of 8 residents is able to make decisions for self, therefore responsible party will not be contact, and 1 out of 8 residents was unable to answer due to cognitive skills. Interviews with staff revealed staff contact responsible party when offering a vaccination clinic to obtain either a release form or verbal approval from residents' responsible party prior clinic day to provide any vaccinations. Documents reviewed reveal, R1 had a durable power of attorney signed on 4/8/11 which notes that if there are other matters other than those listed on POA, the POA is able to make decisions for R1. Per R1’s physician’s report dated; 9/19/22, R1 was noted with dementia. There were no records that R1’s responsible party signed consent for vaccination clinic on 11/16/22. Therefore, this allegation is SUBSTANTIATED. Regarding allegation: Staff do not distribute resident's medication as prescribed. It is alleged resident’s medication was not distributed appropriately. Interviews conducted with residents revealed 7 out of 8 residents stated facility staff provides medications as needed. 1 out of 8 residents handles own medications. 5 out of the 8 residents stated that they are provided as needed medications when requested. Interviews with staff revealed staff centrally stored medications for residents that are on medication assistance, including medication that may be brought by the responsible party. Per staff once the medication is provided it is labeled with residents’ name and it is only used for that resident. Documents reviewed for R1 note R1 was provided with medications as prescribed between August and October of 2022. Medication review conducted on 10/16/22 revealed the following residents were missing the following as needed/routine medications; resident #2(R2) anti-acid liquid, resident#3(R3) acetaminophen 325mg and 500mg, anti-acid liquid, antifungal 2% powder, benzonatate 100mg, fexofenadine 180mg, loperamide 2mg, ondansetron 4mg. Resident #4(R4) acetaminophen 325mg, anti-acid liquid, baqsimi 3mg spray, bysacodyl 10mg suppository, fleet enema, loperamide 2mg, milk of magnesia, naloxone 4mg spray, robafen 10/100mg. Resident #5(R5) chlorhexidine 4% was observed and was noted as discontinued on medication sheet and Mucinex 1200mg observed and not listed on medication sheet, memory armor 300mg(routine medication), anti-acid liquid, ibuprofen 200mg, loperamide 2mg, milk of magnesia, quetiapine fumarate 25mg, Resident #6(R6) baza moisture cream, hydrocodone/APAP 5/235mg, senna 8.6mg, loperamide 2mg was observed and has been discontinued since 5/1/25. (CONTINUED ON LIC 9099C) Resident #7(R7) ivermectin 3mg(routine) observed and noted as discontinued on medication sheet, triamcinolone .025% cream. Resident #8(R8) anti-acid liquid, Benadryl 1-0.1 % cream, fleet enema, ondansetron 4mg, tripe antibiotic ointment, docusate sodium 2mg was observed and not listed on medication sheet. Resident #9(R9) Albuterol, geri-tussin 100mg, ibuprofen 800mg, milk of magnesia. Resident #10(R10) acetaminophen 325mg, docusate sodium 250mg, hydrocortisone 1% cream, loperamide 2mg, lubricant eye .4% drops, milk of magnesia, naloxone 4mg spray. Therefore this allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted and a copy of this report, LIC 9099C, and appeal rights was provided. The investigation revealed the following: Regarding allegation: Staff did not follow COVID protocol. It is alleged facility staff failed to review resident’s vaccination records, resulting in R1 receiving an additional COVID vaccine booster on 11/16/22. Interviews conducted with residents revealed residents received assistance and COVID protocols are followed. Interviews with staff revealed facility assist residents by offering a vaccination clinic yearly. Per staff, they did become aware R1 received the dose during the clinic. Facility staff contacted R1’s physician and was placed on alert checks that day. Facility records provided for review revealed R1’s physician’s report dated: 9/19/22 notes dementia. COVID 19 vaccination record notes R1 had 5th booster shot on 10/13/22 at local stored. On 11/16/22, R1 received a booster shot provided by Rons pharmacy. Per chart notes on 11/16/22 staff spoke with responsible party who acknowledge to provide care for R1 after becoming aware of booster shot given to R1. LPA was unable to interview R1 as R1 passed away on 11/25/23. LPA reviewed mitigation plan last updated on 10/31/24 and Infection control last updated on January 2016. There are no protocols regarding vaccination boosters. Although, facility staff failed to ensure R1 did not receive an additional booster shot within a month. There were no protocols or mandates regarding COVID vaccinations other than recommendations to followed. In addition, R1 was residing in the assisted living portion of the facility from 3/16/20 to 11/15/23 and because we are unable to determine whether R1 willingly participated in obtaining the shot we cannot said R1 was asked to obtained the vaccination shot by staff. Therefore, this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 16, 2025 · control 18-AS-20221117103535

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Oct 17, 2025

87468.1 Personal Rights of Residents in All Facilities : (a)Residents...care facilities for the elderly shall.. rights: (8) To have their representatives regularly informed... of... related to care or services,... This requirement is not met as evidence by: Based on documents and interiviews conducted licensee did not ensure R1's responsible party was notified or provided consent regarding vacination clinic which poses an immediate risk to the persons safety, personal rights, and health of the persons in care.the state’s words, verbatim · CDSS document, Oct 16, 2025

Plan of correction: Administrator will provide in-service training to staff regarding notify, and obtaining consent prior to services related to the residents in care and submit a copy of training with log that includes topic, date, and signatures by POC due date 10/17/25.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(6) · Plan of correction due date: Oct 17, 2025

87464 Basic Services: (f) Basic services shall at a minimum include: (6) Arrangements to meet health needs, including arranging transportation, as specified in Section 87465,... This requirement is not met as evidence by: Based on observation and document review licensee did not ensure R2-R10 had medications available at the faciltiy which poses an immediate risk to the health, safety, personal rights of the persons in care.the state’s words, verbatim · CDSS document, Oct 16, 2025

Plan of correction: Administrator will provided in-service training to medication staff, conduct an audit of medications and submit a copy of training, audit plan to the department by POC due date 10/17/25.

Allegation investigated: Resident not assisted with the administration of medication. Food service inadequate. The resident contract is not adhered to.

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver findings on the allegations listed above. LPA met with Assisted Living Coordinator (ALC), Melissa Villafana and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews, record review and facility tour. For the allegation, Resident not assisted with the administration of medication. During staff interview, 6 out of the 6 staff informed LPA that residents are assisted with their medication. During resident interviews, 4 out of the 7 residents stated staff will assist with their medications. In addition, 3 out of the 7 residents stated they manage their own medications. During medication audit, LPA Rico verify resident’s medication have been dispense properly along with documentation. Unsubstantiated For allegation, food service inadequate. During staff interviews, 6 out of the 6 staff stated the facility has adequate food available for residents. In addition, 6 out of the 6 staff informed LPA that the facility has a variety of food options for residents to select. During resident interviews, 7 out of the 7 residents stated the food service is adequate and is provided in a timely manner. During facility tour and record review, LPA Rico observed the facility had variety of food available for residents. In addition, the facility also has a food menu posted along with options for residents to select. For the allegation, the resident contract is not adhered to. During staff interviews, 3 out of the 6 staff stated residents’ contract is adhered to, no changes are made without resident and their responsible party consent. Based on the evidence found during the investigation, the three (3) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Assisted Living Coordinator (ALC), Melissa Villafana .the state’s words, verbatim · CDSS document, Apr 10, 2025 · control 18-AS-20210203142919

Type of visit: Required - 1 Year

On 1/22/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with Community Resources Manager (CRM), Lyssa Irani who was informed of the purpose of the visit. The facility is licensed to serve 99 non-ambulatory residents of which 10 may be bedridden. The facility also has an approved hospice waiver for 30 residents and LPA was informed 18 residents are currently receiving hospice services at the facility with one (1) deemed bedridden. LPA toured the facility with CRM. The facility is made up of a two-story building designated for assisted living and memory care. The memory care unit wings of the building are approved for delayed egress. CRM tested the delayed egress and LPA observed it to operational. Outside shaded seating is available for resident use. Indoor and outdoor passageways are free of obstruction. There are no bodies of water on the premises. LPA toured the kitchen and observed the facility has more than a two-day supply of perishable food and seven-day supply of non-perishable food items, which are stored in a safe and healthful manner. LPA also observed a cork board in the kitchen noting residents’ food allergies and dietary needs. The facility offers several activities and outings for resident leisure. Medications are secured in medication carts, only accessible to authorized personnel such as medication technicians. Resident files reviewed had updated physician's reports and signed admission agreements. LPA observed fire alarm systems, carbon monoxide detectors, and charged fire extinguishers throughout the facility. CRM contacted the facility's fire alarm company who reported the facility's fire alarms can only be tested by using a designed aerosol can containing a fine mist simulating smoke and spraying it directly towards one (1) of the smoke detectors to trigger the fire alarm. During the visit, the facility did not have the aerosol can available; therefore, facility staff was unable to physically test the fire alarms. As a result, LPA reviewed the facility's System Record of Inspection and Testing (SRIT) dated 3/14/2024, noting the fire alarms were last tested on 3/14/2024, by the facility's fire alarm monitoring company Addax Electric Inc. Per the SRIT, the fire alarms were found to be functioning properly. The facility's last fire drill was conducted on 12/17/2024. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to CRM.the state’s words, verbatim · CDSS document, Jan 22, 2025

Allegation investigated: Staff are not administering medication(s) to resident according to physicians instructions.

On 12/16/2024, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to deliver investigative findings regarding the allegation listed above. LPA met with Administrator, Ricardo Gomez who was informed of the purpose of the visit. It was alleged on 8/6/2024 Resident 1 (R1) was prescribed a medication by a physician and the facility refused to administer it due to R1’s Power of Attorney (POA) agent instructing staff to not administer the medication. LPA reviewed R1’s Physician’s Report (LIC 602A) dated 2/1/24, indicating R1 exhibits confusion and is unable to communicate their needs or manage their own medication. LPA reviewed the durable POA for healthcare signed on 8/5/2020 granting R1’s POA agent the power to make decisions relating to medical treatment including medication. Unfounded LPA conducted an interview with R1’s POA agent who reported they were informed by R1's family that R1 was observed more confused than usual and required medication. R1's POA agent reported R1 has a private caregiver who reported to them that R1's level of confusion was at their baseline. R1's POA agent reported they never instructed facility staff to not administer the medication and were simply waiting on additional information from medical professionals before agreeing to the medication in question due to receiving conflicting information from R1’s family and private caregiver. Assistant Healthcare Director (AHD), Veronica Chavez was interviewed, corroborated the information provided by R1’s POA agent, and reported the facility did not have a signed doctor’s order to administer the medication on 8/6/2024. AHD reported they assessed R1 on 8/6/2024 and 8/7/2024 and R1 was not observed with any symptoms of acute distress. AHD reported the facility received the signed doctor’s order for the medication in question on 8/8/2024 and immediately began administering the medication as prescribed. LPA reviewed R1’s hospice care plan dated 2/2/2024 and conducted an interview with R1’s case manager who corroborated the facility did not receive a signed doctor’s order to administer the medication until 8/8/2024. LPA reviewed hospice’s “Written Confirmation of Telephone Orders” dated 8/7/24 for the medication in question, which noted the physician’s signature was obtained on 8/8/2024. LPA reviewed the Physician’s Order as of 8/16/2024 where the facility documented receiving the medication on 8/8/2024. LPA reviewed R1’s medication administration record for August 2024 and the facility documented administering the medication in question from 8/8/2024 to 8/16/2024. LPA also made contact with the reporting party who reported they do not have any concerns with the care or supervision R1 receives at the facility including medication management. This agency has investigated the complaint alleging “Staff are not administering medication(s) to resident according to physicians instructions”. We have found that the complaint was unfounded, meaning that the allegation was 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 Administrator Gomez.the state’s words, verbatim · CDSS document, Dec 16, 2024 · control 18-AS-20240809151239

Allegation investigated: Staff does not ensure bedroom door for resident is in good repair

On 9/25/2024, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to investigate the allegation listed above. LPA met with Administrator, Ricardo Gomez, Maintenance Manager, Daryl Wilkes, and Health Director (HD), Susanne Larson who were all informed of the purpose of the visit. It was alleged Resident 1's (R1's) bedroom door knob is in disrepair as keys are unable to unlock R1's door from the outside. During today's visit, LPA toured the facility, conducted interviews, and obtained copies of pertinent records. LPA was informed residents have a key to unlock their room from the outside and authorized personnel, such as caregivers, have master keys to open resident rooms from the outside as well. LPA toured R1's room and observed R1's bedroom door knob has a turn button on the inside and requires a keyed entry from the outside. LPA observed R1 physically use their key to unlock their bedroom door from the outside without any issues. R1 was interviewed and reported they have not experienced any issues using their key to unlock their bedroom door from the outside and are not aware of any staff having issues unlocking/opening their door. LPA observed R1 physically lock and unlock their bedroom door from both the inside and outside without issue. LPA also observed facility staff physically use two (2) separate keys to unlock R1's door without issue. Unfounded Five (5) staff were interviewed and all reported being able to use a master key to unlock R1's bedroom door from the outside. Five (5) staff interviewed reported not having knowledge of any resident doorknobs in disrepair. Additionally, LPA reviewed the facility's Maintenance Requests for September 2024 and did not observe a request to repair/replace R1's bedroom door knob. Based on the aforementioned, this agency has investigated the complaint alleging "Staff does not ensure bedroom door for resident is in good repair". We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator Gomez and HD Larson.the state’s words, verbatim · CDSS document, Sep 25, 2024 · control 18-AS-20240923085515

Allegation investigated: Licensee does not ensure the facility has an active Director on site

On 8/16/2024, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to investigate the allegation listed above. LPA met with Community Resources Manager (CRM), Lyssa Irani and Assisted Living Coordinator (ALC), Melissa Villafana who were informed of the purpose of the visit. During today's visit, LPA toured the facility, conducted interviews, and obtained copies of pertinent records. It was alleged as of 8/10/2024, the facility does not have an administrator who possess a Department of Social Services (DSS) administrator's certificate. It was also alleged Melanie Danielson is the Director of Operations (DO) and does not possess an administrator's certificate. LPA reviewed an unsigned Designation of Facility Responsibility (LIC308) dated 7/8/2024, which lists DO Danielson as the designated administrator substitute. Substantiated DO Danielson was interviewed and reported they do not possess a DSS administrator's certificate and are not acting as the facility's current administrator. DO Danielson explained on 7/24/2024, the facility hired a new administrator, Ricardo Gomez, and the change of administrator request was submitted to DSS on 8/1/2024. DO Danielson reported their previous Administrator, Georgianna Mendez's last day with the facility was on 8/9/2024 and Administrator Gomez was scheduled to begin working in the facility on 8/10/2024; however, they have fallen ill and are expected to return to work on 8/19/2024. DO Danielson added the facility asked Administrator Mendez to provide coverage until Administrator Gomez was able to return to work but Administrator Mendez stated they were unable to stay and separated from the facility. DO Danielson added none of the facility's current employees possess a DSS administrator's certificate and no one is acting as the administrator during Administrator Gomez's absence. Based on interviews conducted and records reviewed, 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 9099-D. An exit interview was conducted where a copy of this report was reviewed and provided to ALC Villafana along with the Appeal Rights.the state’s words, verbatim · CDSS document, Aug 16, 2024 · control 18-AS-20240812162904

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Aug 30, 2024

87405(a) All facilities shall have a qualified and currently certified administrator. This requirement was not met as evidenced by: Based on interviews and records reviewed the facility does not have a designated substitute who has an administrator's certificate that can provide coverage during their current administrator's absence. This poses a potential health/safety/personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 16, 2024

Plan of correction: Licensee stated they will review regulation 87405 and submit a new Designation of Facility Responsibility (LIC308), designating a qualified administrator substitute. POC to be submitted to LPA by close of business on 8/30/2024.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit regarding an open complaint that is currently under investigation. LPA was granted entry and met with Executive Director Georgianna Mendez during the visit. During LPA's record review of the resident files, it was revealed Resident One (R1) Physician Report on file was last dated on 03/02/2022. LPA requested a Physician's Report for 2023 and 2024. LVN Health Care Director Martha Batchelor confirmed with Executive Director Mendez the facility did not have an updated Physician Report for R1. Residents diagnosed with Dementia must have an updated Physician's Report completed annually. A deficiency cited under Title 22 Regulation 87705(c)(5) Care of Persons with Dementia will be issued along with a plan of correction. An exit interview was conducted where a copy of this report, LIC 809-D, and appeal rights was provided to Mendez.the state’s words, verbatim · CDSS document, Mar 12, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Mar 29, 2024

Care of Persons with Dementia: (c) Licensees...shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment...and a reappraisal done at least annually... This requirement was not met by: Based on record review and interview, the Licensee did not comply with the above regulation with at least 1 of 4 residents (R1). Record review revealed R1's Dementia diagnosis and their last Physician's Report is dated 3/2/22. This is a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Mar 12, 2024

Plan of correction: Licensee shall obtain an updated Physician's Report for R1 and submit a copy to LPA by the Plan of Correction date of 3/29/24.

Allegation investigated: Staff do not have appropriate training. Staff do not answer residents' call buttons in a timely manner.

On 1/30/2024, Licensing Program Analyst (LPA), Chinwe Nwogene conducted an unannounced visit to conclude the complaint investigation to the allegations listed above. LPA met with Executive Director, Georgianna Mendez and Community Resource Manager, Lyssa Irani who were informed of the purpose of the visit. During the investigation, staff and residents were interviewed and facility records were reviewed. Regarding the allegation “Staff do not have appropriate training”, staff were interviewed who reported staff are behind on training. LPA reviewed staff training log and observed some staff are missing some or haven’t received training (Substantiated). Regarding the allegation “Staff do not answer residents' call buttons in a timely manner”, residents were interviewed who reported sometimes it takes staff long time to respond when resident calls for help. Staff were interviewed who denied that staff does not answer residents' call buttons in a timely manner. Substantiated Staff stated staff are required to respond to resident within 5 minutes of residents calling for help. LPA reviewed facility call log and observed some response time were over two to five hours (Substantiated). Based on LPA’s observations, interviews conducted and record review, the preponderance of evidence standard has been met. Therefore, the above allegations are found to be substantiated. California Code of Regulations Title 22, Division & Chapter number 6 are being cited on the attached LIC9099D. An exit interview was conducted, and this reported was provided along with appeal rights to Georgianna Mendez. Regarding the allegation “Facility heater units are in disrepair” it was alleged that facility heater is broken. Staff were interviewed who stated that the heater in the memory care unit broke on 1/5/2024 but was repaired the same day. Residents were interviewed who stated the heater was broken few weeks ago but was fixed the same day. Staff provided LPA with the service order receipt that shows work was completed on 1/5/2024. LPA toured the facility including the memory care unit and observed the heater operating without issues (Unsubstantiated). Based on interviews with staff and residents and LPA’s observation, there is not enough evidence to support the approve allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed with and provided to Georgianna Mendez.the state’s words, verbatim · CDSS document, Jan 30, 2024 · control 18-AS-20240110095337

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Feb 9, 2024

Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met based as evidence by observation, interview, and record review. The licensee did not comply by having untrained staff assisting residents with personal activities of daily living which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2024

Plan of correction: Executive Director stated staff will be trained and a proof of staff training will be provided to LPA by the POC due date 2/9/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 9, 2024

Residents in All Facilities, 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 based as evidence by observation, interview, and record review. The licensee did not comply by having staff not respond to residents in a timely manner which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2024

Plan of correction: Executive Director stated staff will be trained and a proof of staff training will be provided to LPA by the POC due date 2/9/2024.

Type of visit: Required - 1 Year

On 1/16/2024, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA met with Community Resource Manager, Lyssa Irani who was informed of the purpose of visit. LPA toured the Assisted Living and Memory Care Unit with Lyssa Irani. The following was observed, reviewed, and inspected: The physical plant, in general, was in good repair. The facility is operating in the capacity approved by Community Care Licensing (CCL). The buildings and grounds were free from hazards. Outdoor and indoor passageways were kept free of obstruction. LPA inspected a sample of resident bedrooms and bathrooms in the Assisted Living & Memory Care Unit. Resident bedrooms have the required bedding and furniture; such as clean mattresses, night stands, storage space, and sufficient lighting. Room temperatures were comfortable for residents in care. LPA inspected a sample of resident bathrooms; the bathrooms were equipped and operating in safe and sanitary conditions. LPA measured the hot water temperature in the sampled bathrooms, in which all bathroom sinks measured within regulation. Sampled bathrooms were equipped with non-skid surfaces and grab bars. Bedrooms were equipped with a pull cord system to notify staff of any emergencies. LPA toured the kitchen and dining area. The facility was stocked with a 2-day supply of perishable and 7-day supply of non-perishable food items that were labeled appropriately. The facility had a menu posted and available for review. Dishes, glasses, and utensils were in good condition and stored in a healthful manner. LPA inspected the common areas. LPA observed several carbon monoxide and smoke detectors alarms throughout the facility. Carbon monoxide & smoke detector were tested and functioning properly. There was a locked and centralized storage area for medications, including refrigerated medications. Medications appeared to be dispensed and documented appropriately. The facility had a designated area for resident files and staff files. All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Random staff and residents' records were reviewed. All required postings were posted in prominent areas and throughout the facility. There was adequate seating in the common areas and several activity rooms. LPA observed several activity posters. The facility was also equipped with a complete first aid supplies as well as the first aid manual. LPA inspected the outdoor area of the facility. There was shaded area with seating. Overall, the facility was clean, in good repair, and operating in safe conditions for residents in care. During LPA’s visit, LPA observed facility has no Administrator. Lyssa informed LPA that facility has had no administrator since 1/2/2024. However, the facility has interviewed few prospective candidates and is in the process of hiring a new Administrator this week. No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed, and a copy was provided to Lyssa Irani.the state’s words, verbatim · CDSS document, Jan 16, 2024

Type of visit: Case Management - Health Checks

On 10/3/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to conduct a health and safety visit at the facility to follow up on a fire that took place at the facility on 10/2/2023. LPA met with Community Resources Manager, Lyssa Irani and Maintenance Manager, Daryl Wilkes who were informed of the purpose of the visit. LPA was informed that on 10/2/2023, at approximately 11:30 p.m., there was a fire that ignited in the kitchen. Facility staff contacted the local fire department for assistance. Southern California Edison (SCE) also arrived at the facility to inspect the affected area. SCE determined the fire was not caused by electricity or an electrical fault. The kitchen area was not occupied by residents or staff when the fire started, and there were no injuries to residents or staff reported. The fire department reported the fire sprinkler system at the facility was immediately activated, and the water from the fire sprinklers extinguished the fire. During the visit, LPA inspected the kitchen area and observed a kitchen wall and ceiling tiles to be burned. LPA was informed the facility discarded some food supply that was saturated from the fire sprinkler water. The facility is in the process of replenishing the food supply that perished. The facility anticipates reopening the kitchen on 10/9/2023. A written meal plan will be submitted to LPA by close of business today. Based on Fire Safety Specialist Lorri Larson's inspection, there are only cosmetic damages to the kitchen wall and ceiling as a result of the fire. The kitchen will remain closed until repairs are made and approval is obtained from Fire Safety Specialist Larson. CRM Irani has notified resident's responsible parties of the incident. During today's visit, LPA did not observe any immediate health and safety concerns. A copy of this report was reviewed and provided to CRM Irani.the state’s words, verbatim · CDSS document, Oct 3, 2023