Ivy Park at Hayward

Type of visit: Case Management - Other

Licensing Program Analyst Alicia Delmundo arrived on 08/07/2026 for an unannounced inspection to follow up on a substantiated complaint investigation. LPA met with Business Office Director Rickie Wattanakasaem and explained the purpose of the visit. LPA also spoke over the phone with Regional Operations Specialist Caroline Frangieh who authorized Rickie Wattanakasaem to sign and receive this report. On June 4, 2025, the Department concluded a complaint investigation and substantiated allegation that a resident (R1) sustained a fracture while in care, resident had multiple falls during transfers and staff is not providing appropriate assistance during transfers. On June 4, 2025, the Licensee was cited for violating Health and Safety Code §1569.269(a)(6) Enumerated rights; severability, Health and Safety Code §1569.269(a)(5) Enumerated rights; severability, and Title 22 California Code of Regulations (CCR) 87464(f)(2) Basic Services. At the time of a complaint visit on July 17, 2026, an immediate civil penalty of $500 was issued and the Licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). .....continued on 809C The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not providing appropriate assistance during transfers in which R1 sustained a fracture of the left femur requiring hospitalization and surgery. Today, 08/07/2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on June 4, 2025, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Rickie Wattanakasaemand signature on this report acknowledge receipt of the appeal rights, found on page two of the LIC 421D.the state’s words, verbatim · CDSS document, Aug 7, 2026

Type of visit: Case Management - Other

On this day, July 17, 2026, at 10:22 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the amended report for complaint # 15-AS-20230801150316. LPA met with Business Office Director (BOD) Rickie Wattanakasaem who stated Executive Director (ED) Joseph Villanueva is on the way. ED arrived at 10:40 am. LPA explained the purpose of the visit. On this same day, LPA obtained copy of current LIC500 Personnel Report. No deficiencies cited during visit. Exit interview conducted and a copy of this report and amended complaint report provided.the state’s words, verbatim · CDSS document, Jul 17, 2026

Allegation investigated: Lack of staffing resulting in residents' needs not being met.

On 07/15/2026 at 9:10 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct investigation and deliver finding on the above allegation. LPA met with Executive Director (ED), Joseph Villanueva and explained the purpose of the visit. During the course of the investigation, LPA interviewed ED, 7 staff, 7 residents, Reporting Party (RP), and 3 witnesses. LPA obtained the following documents including but not limited to Resident Roster, Personnel Report (LIC500), February 2026 Staff Schedule, Staff Contact Information, Residence and Services Agreement, Service Plan, Identification and Emergency Information, Resident Information Form, and Physician Report (LIC602A). Continue to LIC9099-C… Unsubstantiated Allegation: Lack of staffing resulting in residents' needs not being met. It was alleged that there’s a lack of staffing resulting in residents' needs not being met. Interviews with ED, S1, and S2 stated that there are at least 5 people during the daytime shifts. S2 stated that if a staff member calls out for their shift, S2 will ask another staff member to pick up an extra shift, or the facility will request from temporary agency to assist with staffing. Interview with S3, S4, S5, S6, and S7 stated that on their floor there is enough staff members to meet the residents’ needs. Interview with S6 also stated that S6 can also assist other staff members with transferring residents if needed. LPA interviewed 7 residents. Interviews with R2, R4, R5, R6, and R7 stated that the amount of staff on the floor are sufficient in providing the care and needs for them and/or their partners that reside in the same room. R4 and R5 stated that the floor could use more staffing for how many residents residing. However, R4 and R5 stated that the number of staff on each shift still meets the needs of the residents and they assist with the residents’ Activities of Daily Living (ADLs). Interviews with W2 and W3 indicated that they visit their family members often and stated that they have observed staff provide services such as dressing, toileting, and/or shower assistance to their family members. Interview with W3 who live in independent Living stated that they are providing and assisting with R6’s ADLs. Based on information obtained from RP, they indicated that there's residents that need three persons assist. However, LPA reviewed R1 and R11’s previous and current service plan that showed both residents need a two person assist when transferring and not three persons assist. A review of the current LIC500 and staff schedule indicates that there is staffing to meet the needs of the residents. Based on interviews and record review conducted, the above allegation that lack of staffing resulting in residents’ needs not being met 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, therefore the allegations are unsubstantiated. There is no deficiency noted. Exit interview was conducted with Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 15-AS-20260213171042

Type of visit: Office

At 2:00 p.m. on this day, July 14, 2026, a virtual meeting was called. The meeting was attended by the following: Licensing Program Manager Jeremy Fong Licensing Program Manager Lizette Chan Acting Licensing Program Manager Grace Luk Licensing Program Analyst Alicia Delmundo Executive Director Joseph Villanueva Senior Vice President of Operations Scott Carlson Vice President of Operations Andrew Moret Regional Health Services Director Kevin Jorgensen The following were discussed: Type A Deficiencies: Section 87411(a) Personnel Requirements - cited on May 13, 2026. On February 28, 2026, the front desk staff left for few minutes and a resident was able to leave the facility unnoticed. Resident was moved to Memory Care Unit after the incident. Section 87705(d) Care of Persons with Dementia - cited on December 2, 2025 due to front/exit door not having auditory signal and a resident able to leave the facility unnoticed on November 12, 2025. The LIC602A Physician's Report indicated this resident has major neurocognitive disease and cannot leave the facility unassisted. ......continued on 809C During the meeting, facility management staff provided detailed information explaining the circumstances pertaining to the elopements. The facility management staff also provided information showing that a good faith effort has been made to address persons who cannot leave unassisted from exiting unnoticed. Facility management stated and provided the following steps that they took: They applied for the Department's offered Technical Support Program. Installed a wanderguard system covering exit doors that sends signals the system and care manager/caregiver. Front desk is covered 24 hours/day. Conducted additional training on elopement. Exit interview conducted and copy of this report provided via email. .the state’s words, verbatim · CDSS document, Jul 14, 2026

Type of visit: Case Management - Other

While at the facility for other reason, Executive Director (ED) Joseph Villanueva conferred with Licensing Program Analyst (LPA) Delmundo. ED stated that in response to the facility citation (deficiency issued on May 26, 2026) on having scissors in the art studio, they have implemented twice per day checks of the art studio drawers & cabinets. ED also stated that residents bring in their own items, and that he cannot think of a solution to monitor the art studio 12 hours per day for each resident who comes in and that he would like to put in every possible intervention. The following were discussed: · Calling for a meeting with residents and/or residents’ family members. · Checking LIC602A Physician’s Reports to ensure residents who bring their own materials like scissors are able and capable of having the items with them and ensure other residents who do not have the capability do not have direct access. · Installation of camera in the common area. · Ensuring items that can pose risks to residents are not readily accessible. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Jul 2, 2026

Type of visit: Case Management - Other

On this day, July 2, 2026, at 12:35 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the amended report for complaint # 15-AS-20230801150316. LPA met with Executive Director Joseph Villanueva and explained the purpose of the visit. No deficiencies cited during visit. Exit interview conducted and a copy of this report and amended complaint report provided.the state’s words, verbatim · CDSS document, Jul 2, 2026

Type of visit: Case Management - Health Checks

On this day, May 26, 2026, Licensing Program Analyst (LPA) Delmundo conducted a health and safety inspection as a result of the Department receiving a Priority 2 complaint (Complaint Control # 15-AS-20260522142733). LPA met with Executive Director (ED) Joseph Vilanueva and informed the reason for visit. LPA toured the facility with ED. LPA inspected the dining area on the first floor, art room, activity area. Salon and housekeeping and supplies rooms on the first floor were observed locked. Dining and activity rooms on the second floor were also inspected. Laundry rooms on other floors were checked and observed locked. Hot water temperature in the bathroom of one of the resident's apartments was tested and measured at 114 degrees Fahrenheit. LPA randomly selected 7 residents apartments for inspection - 1 each on 1st, 3rd, 4th floors, and 2 on 2nd and 5th floors. LPA observed the following: -at 12:02 pm, 2 pairs of scissors unlocked in the art room. -at 12:17 pm, wound cleanser, scissors, Neosporin in the dining table and Lysol cleaning agent in the bathroom in one of the resident's apartments. - at 12:18 pm, dirty/soiled carpet flooring in one the resident's apartments. -at 12:27 pm and 12:33 pm, heavily spoiled carpet flooring in other 2 residents' apartments. .....continued on 809C Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $250.00 civil penalty is assessed for repeat violation within 12 month period for deficiency section # 87309(a). Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalty. Deficiencies and plan and proof of corrections were discussed with the Executive Director. Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, May 26, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: May 27, 2026

87309 Storage Space and Access (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 above in unlocked scissors, Lysol, Neosporin and wound cleanser which pose an immediate risks to persons in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Executive Director (ED) had the items locked. In addition, ED to in-service the staff and submit copy of training topic with attendees signatures by 5/27/26. A $250.00 civil penaty is assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 9, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above in 3 out of 7 apartments inspected with soiled/dirty carpet flooring which pose a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Executive Director stated he'll have the carpet flooring deep cleaned. Pictures to be submitted by 5/26/26.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to Unusual Incident Report (UIR) the facility submitted. LPA met with Executive Director (ED) Joseph Villanueva and informed the reason for visit. UIR indicated that approximately 3:36 pm on February 28, 2026, resident (R1) was observed returning to the community from outside. Surveillance footage was reviewed and determined that R1 had left the facility unassisted through the main entrance door at approximately 2:58 pm. R1 cannot leave the facility unassisted. On this day, LPA obtained copies of resident roster and staff schedule. LPA inspected the entrance/exit doors with ED, conducted interviews and reviewed and obtained copies of R1's including but not limited to the following documents: Resident Information Form; LIC602A Physician's Report; Mini-Mental State Examination; Individualized Service Plan ED stated that at the time R1 left the facility, R1 was in Assisted Living. After the incident, R1 was provided 1:1 caregiver until R1 moved to Memory Care Unit about 2 week ago. ED also stated that the time the incident happened, the concierge/front desk staff left for few minutes. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Any repeat violation within 12 month period may result in civil penalty. Deficiency was discussed with the ED. Exit interview conducted. Appeal Rights and copy of this report provided.the state’s words, verbatim · CDSS document, May 13, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 14, 2026

87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed as necessary........... -This requirement is not met as evidenced by: -Based on interviews and record review, the licensee did not comply with section above when R1 was able to leave the facility unnoticed which posed an immediate risk to person in care.the state’s words, verbatim · CDSS document, May 13, 2026

Plan of correction: Corrected. The following were conducted: 1. Retraining of staff - copies obtained by LPA on this day, 5/13/26. 2. Wander guard installed on all entrance/exit doors. 3. Resident was moved to Memory Care Unit.

Allegation investigated: Staff do not answer residents calls for assistance timely.

On this day, January 27, 2026, 1t 12:10 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation and close the complaint. LPA met with Executive Director (ED) Joseph Villanueva and informed the reason for visit. During the course of investigation, LPA obtained copies of residents rosters and staff schedule. LPA reviewed residents' records and obtained copies of including but not limited to the following documents: Admission Agreement; LIC602 A Physician's Repors; Residents' Assessments/Care Plan. LPA interviewed 5 residents and staff on July 17, 2025, January 7, 2026 and January 27, 2026. .....continued on 9099C Substantiated Two of the residents stated there were times when they pressed their call button and it takes time for the staff to respond. One of these residents stated when his Home Health nurse pressed the call button for assistance to change his clothes, the nurse end up changing and took 30 minutes for the caregiver to respond and at that time he was already in the dining room. On January 7, 2026, resident (R5) pressed the call button and the caregiver assigned did not respond. LPA interviewed the assigned caregiver who stated she was assisting another resident at the time R5 called for assistance and she didn't attend to R5 nor called her partner caregiver to check R5. On January 27, 2026, one of the staff interviewed stated seeing reports where resident fell at night and no caregiver responded. Based on information gathered, the preponderance of evidence is met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan of correction were discussed with ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided. Allegation: Due to lack of staff, residents have had multiple falls. Unusual Incident Reports submitted by the facility from July 2025 to January 20, 2026 pertaining to fall incidents were reviewed of which showed mostly were un-witnessed. All the staff interviewed stated they don't feel there's staffing issues. One of these staff stated staffing is good but more is better. Five residents interviewed stated they don't feel staffing is an issue. Therefore, the allegation is unsubstantiated. Allegation: Staff do not check on residents every 2 hours. Two of the staff stated residents in Memory Care are on two hour check throughout the day. Another staff stated the care providers are not required to check the residents in Assisted Living every 2 hours, and that the 2 hours checking is based on situation and should be on the Care Plan. All residents interviewed including one whose spouse is also In Memory Care stated they are not on every 2 hour check. Therefore, the allegation is unsubstantiated. Based on interviews and records reviews, the allegations are unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Jan 27, 2026 · control 15-AS-20250709140228

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Feb 10, 2026

§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) 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 records review and interviews, the licensee did not comply with the section when staff did not respond to residents' call timely which posed a potential health, safety and/or personal right risks to persons in care.the state’s words, verbatim · CDSS document, Jan 27, 2026

Plan of correction: Executive Director to in-service the staff and submit copy of training topics with attendees signatures by 2/10/26.

Type of visit: Case Management - Incident

On this day, January 27, 2026, Licensing Program Analyst (LPA) Delmundo conducted a case management visit in response to the Unusual Incident Report (UIR) submitted by the facility for resident (R1) which LPA received on January 20, 2026. UIR indicated that on January 19, 2026, R1 had unwitnessed fall and was found lying on the floor on her side and was noted with bleeding to the right cheek. 9-11 was contacted and R1 was sent out, family member and R1's primary care physician were informed. R1 returned to the facility with stitches to the laceration. On this same day, January 27, 2026, LPA interviewed R1 who stated she rushed in wheeling her wheelchair resulting to falling out. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Jan 27, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to Unusual Incident Reports (UIRs). SOC341 and Death Report submitted by the facility. LPA met with Associate Executive Director (AED) Rosana Frias and informed the reason for visit. UIRs indicated the following: 1. Resident (R1) UIR indicated that on 11/12/25, the facility received a call from a community that R1 was at the community's lobby. The Resident Care Coordinator and Memory Care Director went to the community and brought R1 back to facility. Family member was informed. 2. Death Report (DR) for resident (R2) DR indicated R2 passed on 11/09/25. R2 was in hospital ICU at the time of death. R2 was sent out to the emergency on 9/29/25 when R2 cried of head pain after an unwitnessed fall. 3. Resident (R3) On 11/24/24, R3 reported missing $800 in cash in her apartment. Executive Director met with R3, checked R3's apartment and didn't find any cash in the apartments and bags R3 said R3 keeps. There was no witness to the said incident. The facility also submitted a copy of SOC341. continued on 809C On this same day, 12/02/25, LPA reviewed residents' files and obtained copies of including but not limited to the following documents: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Reports; Care Plan; LIC621 Client/Resident Personal Property Valuables. LPA checked the front door and conducted interviews. LPA observed the following: -at 12:00 pm, R1's LIC602A Physician's Report showed R1 has major neurocognitive disorder and cannot leave the facility unassisted. R1's assessment dated 11/17/25 not consistent with current care need. Assessment indicated resident wanders only within the common areas of the secured community. -at 12:20 pm, the front entrance/exit door does not have auditory signal. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalty. Deficiencies and plan and proof of corrections were discussed with AED. Exit interview conducted. Appeal Rights,LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Dec 2, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(d) · Plan of correction due date: Dec 3, 2025

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement......... -This requirement is not met as evidence by: -Based on observation and interviews, the licensee did not comply with the section above in front/exit door not having auditory signal and R1 was able to leave the facility unnoticed.the state’s words, verbatim · CDSS document, Dec 2, 2025

Plan of correction: Auditory signal's battery was replaced while LPA was at the facility. AED stated they will start having the auditory signal checked everyday. In addition, AED to conduct in-service training and submit copy of training topic with attendees signatures by 12/03/25

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(1)(C) · Plan of correction due date: Dec 16, 2025

87463 Reappraisals: (b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition.... (1)..(C) Behavioral expression, as defined in Section 87101, Definitions, that may result in harm to self or others, such as unsafe wandering, elopement, hallucinations..... -This requirement is not met as evidence by: -Based on record review, the licensee did not comply with the section when R1's assessmrent was completed but not consistent with the current need which poses a potential satety risk to person in care.the state’s words, verbatim · CDSS document, Dec 2, 2025

Plan of correction: AED to have the assessment corrected and submit copy by 12/16/25.

Type of visit: Required - 1 Year

At 1:45 pm on this day, 10/30/25, Licensing Program Analyst (LPA) Alicia Delmundo conducted an unannounced annual required inspection. LPA met with Executive Director (ED) Joseph Villanueva and informed the reason for visit. Facility is a seven story building, of which 1st floor to 5th floors house assisted living residents. LPA toured the facility with ED. LPA inspected the common areas, activity rooms, kitchen, dining rooms on the first and 2nd floors, Life Enhancement area, lounge/bistro. theater, fitness center/room, courtyard and back patio. Salon, housekeeping and supplies rooms, art studio, massage/therapy room and fitness center on the first floor were inspected. Electrical and housekeeping supply rooms, laundry rooms on other floors were checked. Food supplies were observed good for 7 days of non perishables and 2 days of perishables. LPA randomly selected 10 residents apartments for inspection - 2 each on 1st, 2nd, 3rd, 4th and 5th floors. Facility has carbon monoxide and smoke detectors that are in operating condition. Hot water temperature in one of the residents' bathroom on the 2nd floor was tested and measured at 117.1 degrees Fahrenheit. Facility has evacuation chairs on stairwells. Facility conducts disaster drills at least every quarter and records showed last fire, disaster and earth quake drills last conducted 9/26/25, 9/24/25 and 10/29/25 respectively. ....continued on 809C LPA observed the following: -at 2:30 pm, razor in the bathroom of 1 of the apartments in memory care unit. -at 2:55 pm, Tylenol in the medicaiton cabinet in the bathroom of the resident on the 4th floor of which the LIC602A Physician's Report showed can not administer and store own medications The following updated/current documents to be submitted by November 13, 2024: 1. LIC308 Designation of Facility Responsibility 2, LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. $3M Liability Insurance certificate Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalty. Deficiencies and plan and proof of corrections were discussed with ED. Due to time constraint, LPA will come back to continue inspection. Exit interview conducted. Appeal Rights,LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Oct 30, 2025

Allegation investigated: -Resident (R1) sustained a fracture while in care. -Resident (R1) had multiple falls during transfers. -Staff is not providing appropriate assistance during transfers.

On this day, June 4, 2025, at 2:15 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Executive Director (ED) Nansiela 'Nancy' Randhawa, and informed the reason for visit. During the course of investigation, the Department obtained copies of including but not limited to the following resident’s documents: LIC601 Identification and Emergency Contact Information; Appraisal/Assessment; LIC602A Physician's Report; Unusual Incident Reports (UIRs); facility notes; doctor's notes; medical records. Copies of resident roster and staff schedules were also obtained. The following were interviewed: resident’s (R1) family member (FM1) on 8/15/23; staff (S1, S2, S3, S4) and Associate Executive Director (AED) on 8/21/23; residents (R1, R2, R3, R4) on 8/21/23; resident (R5) on 9/06/23 ....continued on 9099C (page 2) Substantiated Page 2 Allegation: Resident sustained a fracture while in care. LIC602A Physician’s Report showed R1 as non-ambulatory, cannot bathe self and not able to care for own toileting needs. FM1 stated she took R1 to the hospital in April 2023 where R1 was assessed and determined R1 needs a wheelchair. R1 was then upgraded to a tier two, which means R1 needs two people assistance during transfers. FM1 further indicated she has witnessed R1 being transferred by only one person “multiple times”. Incident reports dated 2/27/23, 4/07/23, 6/29/23, 7/14/23, 7/15/23, and 7/26/23 noted R1 sustaining the same type of fall while the facility staff walked R1 to the bathroom. Incident report dated 7/26/23 noted that R1 was helped up from bed and was about to walk with walker to the bathroom when R1’s legs gave out and R1 indicated her legs getting weak and were hurting. R1 fell on her knees and facility staff helped R1 sit up. Lift assist was called to help get R1 up, but R1 could not get up after several attempts with the medics. R1 was taken to the hospital. Medical Records reflected that R1 sustained a displaced supracondylar fracture without intercondylar extension of the lower end of her left femur. Based on records review and interviews, the allegation is substantiated. Allegation: Resident had multiple falls during transfers. FM1 stated she took R1 to the hospital in April 2023 where R1 was assessed and determined R1 needs a wheelchair. R1 was then upgraded to a tier two, which means R1 needs two people assistance during transfers.FM1 further indicated she has witnessed R1 being transferred by only one person “multiple times”. Incident reports dated 02/27/2023, 4/07/23, 6/29/23, 7/14/23, 7/15/23, and 7/26/23 note R1 sustaining the same type of fall while the facility staff walked R1 to the bathroom. Lift assist had to be called each time in order to get R1 up. Facility staff admitted that R1 would fall “every single day”. All facility staff interviewed stated they did not believe they could provide the level of care R1 required but kept R1 at the facility anyway. In April of 2023, R1 returned from the hospital to the facility confined to a wheelchair, however, the wheelchair did not fit through R1’s bedroom or bathroom door. Two facility staff would have to physically lift R1 out of R1’s wheelchair and into a standing position supported by R1’s walker. Facility staff would then walk behind R1 as she walked into her bedroom and bathroom. R1’s physical condition prevented her from walking at all which caused R1 to fall constantly. Therefore, the allegation is substantiated. ......continued on 9099C (page 3) Page 3 Allegation: Staff is not providing appropriate assistance during transfers. FM1 stated she took R1 to the hospital in April 2023 where R1 was assessed and determined R1 needs a wheelchair. R1 was then upgraded to a tier two, which means R1 needs two people assistance during transfers. FM1 further indicated she has witnessed R1 being transferred by only one person “multiple times”. LIC602A Physician’s Report showed R1 as non-ambulatory, cannot bathe self and not able to care for own toileting needs. Incident reports dated 2/27/23, 4/07/23, 6/29/23, 7/14/23, 7/15/23, and 7/26/23 note R1 sustaining the same type of fall while the facility staff walked R1 to the bathroom. Therefore, the allegation is substantiated. Based on the Department’s interviews and records review conducted, the preponderance of evidence has been met, therefore the above allegations are found to be substantiated. Deficiencies are cited from Title 22 California Health and Safety Code and Regulations and listed on 9099Ds. A $1,000.00 civil penalty is assessed for deficiency section 1569.269(a)(6) which is also a repeat violation within 12 month period. Civil penalty for this deficiency will continue for $100.00 per day until corrected. Additional civil penalty may be assessed based on Health and Safety Code 1569.49(f). Failure to submit proof of corrections by plan of correction due dates for the other deficiencies and any repeat violation within 12 month period may result in additional civil penalties. Deficiencies, civil penalty, and plan and proof of corrections were discussed with the ED. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Jun 4, 2025 · control 15-AS-20230801150316

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Jun 5, 2025

§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff.......... -This requirement is not met as evidenced by: -Based on records reviews and interviews, the licensee did not comply with the section above in not meeting R1’s needs of being non-ambulatory by walking R1 to the bathroom causing R1 to fall and sustained injury which posed an immediate health, safety and/or personal rights risks to person in care.the state’s words, verbatim · CDSS document, Jun 4, 2025

Plan of correction: Executive Director to do the following and submit proof by 6/05/25: 1. Revisit the facility's transfer procedures. 2. In-service the staff A $1,000.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(5) · Plan of correction due date: Jun 5, 2025

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations....... -This requirement is not met as evidenced by -Based on records review and interviews, the licensee did not comply with the section above in not safely meeting R1’s needs resulting to R1's constant falls which posed an immediate health, safety and/or personal rights risks to person in care.the state’s words, verbatim · CDSS document, Jun 4, 2025

Plan of correction: Executive Director to in-service the staff and submit copy of training topic(s) with attendees signatures by 6/05/25.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87564(f)(2) · Plan of correction due date: Jun 5, 2025

87464 Basic Services (f) Basic services shall at a minimum include: (2) Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services. -This requirement is not met as evidenced by: -Based on records review and interviews, the licensee did not comply with the section above in not meeting R1’s transferring needs by walking R1 to the bathroom which posed an immediate health, safety and/or personal rights risks to person in care.the state’s words, verbatim · CDSS document, Jun 4, 2025

Plan of correction: Executive Director to add to inservice training and submit copy of training topic(s) with attendees signatures by 6/05/25.

Type of visit: Case Management - Deficiencies

While the Department conducted investigation of complaint (Control # 15-AS-20230801150316) and upon review of records and interviews, it was learned that fift assist had to be called each time in order to get R1 up. Facility staff admitted that R1 would fall “every single day”. All facility staff interviewed stated they did not believe they could provide the level of care R1 required but kept R1 at the facility anyway. LPA discussed the above with Executive Director (ED) Nansiela 'Nancy' Randhawa. Deficiency is from Title 22 California Code Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Jun 4, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1568.03(b) · Plan of correction due date: Jun 19, 2025

§1568.03 License requirements; levels of care; application of chapters; multiple licenses; enjoining violations: (b) A facility may accept or retain residents requiring varying levels of care. However, a facility shall not accept or retain residents who require a higher level of care than the facility is authorized to provide. …….. -This requirement is not met as evidenced by; -Based on interviews and record review, the licensee did not comply with the section above in retaining a resident who needed higher level of care which posed an immediate health, safety and/or personal rights risks to person in care.the state’s words, verbatim · CDSS document, Jun 4, 2025

Plan of correction: R1 is no longer at the facility. Executive Director stated she'll do the following: 1. In-service the staff. 2. Ensure that resident needing higher level of care will be move-out accordingly.

Allegation investigated: Facility failed to issue appropriate refund.

On this day, 04/22/2025, at 1:05 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegation and close the complaint. LPA met with Associate Executive Director (AED) Rosana Frias and Executive Director (ED) Nanensila 'Nancy' Randhawa, and informed the reason for visit. It was alleged that resident (R1) was moved-out on 05/04/2024 but the facility was able to withdraw the full rent payment for 05/2024. R1's responible person (FM) has paid the facility $780.00 prorated amount for May 1-4, 2024; however, when FM was issued the refund, FM only received $7280.00, which means the prorated amount of $780.00 was deducted despite FM paying the facility the prorated amount. ....continued on 9099C Unfounded During the course of investigation, LPA obtained copies of R1's Admission Agreement and document showing R1's move-out date which confirmed R1 moved-out on 05/04/2024. LPA also obtained copies of Authorization Agreement for Direct Payment (ACH) and payment records for R1. LPA interviewed FM on 01/21/2025 who stated he cancelled the automatic payment for 05/2024, somehow the payment still went through but the facility got the money before he cancelled the auto payment. FM further stated that he received a refund check of $7280.00 but when he deposited it, it bounced. On 01/29/2025, LPA received an e-mail from FM stating that it was a mistake on his end with the bank. LPA interviewed AED on 01/24/2025 who stated she is aware of issues regarding the refund and that the $7280.00 check refund was cancelled by MorningStar. AED called and spoke with FM on 02/06/2025 regarding the issue. The telephone call was followed by an email to FM confirming the communication between her and FM and that no balance is owed by either FM and facility. Based on information gathered, the allegation is closed as unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 15-AS-20250117103258

Type of visit: Case Management - Other

While at the facility for other reason, Licensing Program Analyst (LPA) Delmundo learned that the facility's new administrator/executive director is Nanensila 'Nancy' Randhawa. LPA verified, and Ms. Randhawa stated she started on April 7, 2025. LPA discussed the Title 22 Regulations pertaining to hiring a new administrator. LPA received on this same day copies of the following: 1. Ms Randhawa's LIC501 Personnel Record, resume and administrator certificate 2. LIC308 Designation of Facility Responsibility 4. LIC500 Personnel Report 5. Board letter Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Apr 22, 2025

Allegation investigated: -Facility staff did not administer medication to resident according to physician's instructions. -Resident sustained fall(s) resulting to injuries due to lack of supervision. -Staff did not safeguard resident's personal belongings. -Facility staff did not notify the resident's authorized representative of resident's injuries.

On 3/8/25 at (time) LPM Jeremy Fong arrived unannounced to deliver the findings for the above allegations. LPM met with Community Relations Director, Henrietta Beshares, and informed her of the purpose of visit. During the course of investigation, the following resident’s documents were obtained: medical records; admission agreement; LIC601 Identification and Emergency Information; LIC602A Physician's Report; Pre-placement Appraisal; Reappraisals (2019, 2020 and 2021); LIC621 Client/Resident Personal Property and Valuables; LIC622 Centrally Stored Medication and Destruction Record; Medication Administration Records; incident reports (2019, 2020 and 2021). The Department also obtained copies of resident roster and staff schedule. Family member (FM), staff, medical providers (PCP, MD1 and MD2) and residents were interviewed on 10/2021, 12/2021, 1/19/2022, 8/2022 and 1/2023. Medical records and facility Call Button Log were reviewed. Unsubstantiated Allegation: Facility staff did not administer medication to resident according to physician's instructions. Unsubstantiated. It was alleged that facility staff did not administer medication to resident (R1) according to physician's instructions. Reporting party (RP) stated R1 was admitted to the facility on 2016, and from 2016 to 2019, R1 was administered insulin. It was further alleged that the Humalog injection was discontinued on 2019, and facility retained R1 that the facility could no longer care for as R1 has diabetes and needs insulin. These dates are all prior to the current License for this facility issued on 10/09/2020. R1’s family member (FM) was interviewed who stated R1 was admitted to the facility 2016 and had (Humalog) insulin medication which facility discontinued to administer July 2019. FM received a bill in October 2019 that did not include R1’s insulin medications. FM indicated that staff S1 (facility’s registered nurse) told FM that as of October 2019, staff stopped giving R1 insulin injections. Review of records showed the facility sent request to R1’s primary care physician (PCP) to discontinue the Humalog sliding scale as Casa Sandoval scope of service does not allow the use of sliding scale insulin since non-clinical caregivers are assisting with the injections. PCP ordered Humalog sliding scale to be discontinued on July 24, 2019. When R1 was seen by PCP the After Visit Summary dated November 5, 2019 showed medications that were ordered to be continued included Humalog and Novolog. PCP indicated during interview on January 6, 2022 that during R1’s visit on November 5, 2019, R1 was still to be on insulin injections and nothing was changed with the dosages. However, it was not established that this information had been conveyed to the current Licensee. Hospice care was ordered for R1 and was started on November 22, 2019. Some medications were discontinued (dc’d) by hospice doctor (MD1), and while MD1 stated during interview that all medications would have been discontinued when the resident was placed on hospice, MD1’s list didn’t include Humalog and Novolog to be discontinued. November 2019 Medication Administration Record showed Humalog was not administered from 11/05/19 to 11/22/19, and Novolog was discontinued on November 22, 2019. R1 was discharged from hospice care June 20, 2020. These actions took place prior to the current License. Further, the PCP stated having had no knowledge of the resident being placed on hospice and changes made to the resident’s medication regimen. Based upon interviews, records review, and conflicting information obtained, the Department has investigated this allegation and it could not be established that the current Licensee was made firmly aware that diabetic medications were to be continued and/or restarted. Although the allegation may have occurred or is valid, there is insufficient information to reach a preponderance of evidence. Therefore the allegation is Unsubstantiated. Allegation: Resident sustained fall(s) resulting to in injuries due to lack of supervision. Unsubstantiated. A review of the call button log from 6/1/2021 to 7/31/2021 showed 127 safety check-ins staff conducted on R1. R1 never pressed the emergency button to request staff assistance. None of the facility staff were aware R1 had sustained a fracture as R1 never complained of any pain, other than back pain from sitting in the recliner too long. Staff found out about the fracture when R1’s son, FM, reported it to the facility after R1’s hospitalization. During FM’s interview, FM stated R1 initially denied falling but later recalled she had and did not tell staff. A review of Hospital Discharge Summary stated R1 sustained a left femoral fracture from a fall. Orthopedist (MD2) confirmed R1’s fracture was due to a fall but was unable to tell whether the fracture was old or new. The Department interviewed R1 but R1 was unable to provide information. Based upon interviews, records review, and conflicting information obtained, the Department has investigated this allegation and determined that it could not be proven that R1s injuries were recent or new, nor that they were the result of insufficient care and supervision. Although the allegation may have occurred or is valid, there is insufficient information to reach a preponderance of evidence. Therefore, the allegation is Unsubstantiated. Allegation: Staff did not safeguard resident's personal belongings. Unsubstantiated. It was alleged that staff and other residents were taking R1 personal belongings such soda in R1 refrigerator and other items. Staff (S1 and S2) were interviewed on 1/31/23 and 1/20/23. S1 stated she was not aware that R1 had soda in R1’s refrigerator. R1 was given Ensure and Ensure is labelled with resident’s name, and kept in medication cart. S2 indicated she never heard nor has anyone reported to her that R1's soda or other items are missing. It was never communicated to her by FM that R1's soda and other items were missing; otherwise, S2 will be involved and will the communicate with the staff. Missing items were never reported to them. Based upon interviews, records review, and conflicting information obtained, the Department has investigated this allegation and could not determine the factual accuracy that personal items had gone missing. Although the allegation may have occurred or is valid, there is insufficient information to reach a preponderance of evidence. Therefore, the allegation is Unsubstantiated. Allegation: Facility staff did not notify the resident's authorized representative of resident's injuries. Unsubstantiated. The Department interviewed FM and staff. During FM’s interview, FM stated R1 initially denied falling but later recalled she had and did not tell staff. R1 was interviewed and stated her leg problem was due to old age. Staff (S1, S3, S4, S5, S6, S7, S8 and S8) were interviewed on 12/08/21, 12/16/21, 12/30/21. These staff stated R1 didn’t complain of pain, not being aware that R1 had fallen and sustained fall. S1 stated she was not aware R1 had fallen and sustained a fracture. S1 indicated she came to know after R1 was hospitalized. Based upon interviews, records review, and conflicting information obtained, the Department has investigated this allegation and could not establish that facility staff had been aware of, and/or, informed that R1 had sustained a fall prior to going to hospital, nor whether the fracture found was recent or old. Although the allegation may have occurred or is valid, there is insufficient information to reach a preponderance of evidence. Therefore, the allegation is Unsubstantiated. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 8, 2025 · control 15-AS-20210901144412

Allegation investigated: Facility not responding to resident's (R1) responsible person.

On this day, 01/24/2025 at 11:55 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a 10 day initial complaint investigation for the above allegation above. The front desk staff stated the Interim Executive Director (IED) Rosana Frias is not at the facililty. LPA called and spoke with IED over the phone, and explained the reason for the visit. IED gave permission to have the Wellness Director Gabriella Johnson to sign and receive this report. LPA conducted interviews with staff and obtained copies of R1's Admission Agreement and document showing R1's move-out date. It was reported that R1's family member (FM) has been reaching out to staff (S1) and facility's corporate office since May 2024 regarding refund and no one returned FM's call. .......continued on 9099C Substantiated Review of email communication between staff (S1) and FM showed FM has been following-up on the refund. Email threads between FM and S1 showed FM has been following-up since September 2024. On 1/03/25, FM sent another email to S1 stating FM was having issues with S1 getting back to FM and that S1 was asked for the best way to contact S1 which S1 said via email. On 1/04/25, S1 responded to FM stating the ED who was included on the previous emails no longer work at the facility but will have the IED give FM a call on 1/06/25. LPA interviewed the IED who stated though she is aware of the refund issues, she does not know the details. IED stated she didn't call nor send email to FM. Based on information obtained, the preponderance of evidence standard has been met, therefore, the allegation is substantiated. Deficiency is cited per Title 22 California Code of Regulations, and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the IED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Jan 24, 2025 · control 15-AS-20250117103258

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(9) · Plan of correction due date: Feb 7, 2025

87468.1 Personal Rights of Residents in All Facilities (a) .......(9) To have communications to the licensee from their representatives answered promptly and appropriately. -This requirement is not met as evidenced by --Based on document review and interviews, the licensee did not comply with the section above in not responding to R1's responsible person.the state’s words, verbatim · CDSS document, Jan 24, 2025

Plan of correction: The IED stated she'll communicate with R1's responsible person. Proof to be submitted by 2/07/25.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: -Facility failed to seek medical attention for resident (R1) in timely manner. -Facility improperly assisted resident (R1) with medical needs. -Staff not responding to responsible person's request for communication regarding resident's (R1) care and services. -Staff interfere with residents' mail.

On this day, 1/16/25, at 12:00 noon, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegations and close the complaint. LPA met with Associate Executive Director (AED) Rosana Frias. and informed the reason for visit. During the course of investigation, LPA obtained copies of staff schedule and resident roster. LPA obtained copies of including but not limited to the following: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Reports; doctor's orders of medications; Medication Administration Records (MAR); LIC622 Centrally Stored Medication and Destruction Records; doctor's orders of medicaitons; facility notes; blood pressure log; facility's records of communication with Pine Park Health and R1's responsible person (FM). LPA interviewed staff (former ED, AED, S1, S2, S3, S4, S5, S6, S7) on 3/22/24 and 1/16/25, obtained information from FM on 5/22/24, interviewed residents (R2, R3) on 1/16/25 and obtained information from Pine Park Health staff (PP1). ....continued on 9099C (page 2) Unsubstantiated Page 2 Allegation: Facility failed to seek medical attention for resident (R1) in timely manner. Reporting party (RP) stated that R1 has doctor's order to monitor blood pressure (BP) and was prescribed medication back in 2022. RP further stated that on 2/19/24, Pine Park Nurse Practitioner (W1) called R1's responsible person (FM) and told FM that R1 will be sent out due to the BP being out of control. RP alleged that facility did not call 9-1-1. LPA reached out to W1 but W1 did not return LPA's call. PP1 confirmed W1 has an order sent to the facility to check R1's blood pressure from 2/07/24 to 2/14/24. Review on Unusual Incident Report showed staff (S1) called 9-1-1 on 2/19/24 and that W1 was notified and that FM was aware. LPA interviewed S1 who confirmed she called 9-1-1 and that R1 was sent out due to high blood pressure. Based on information gathered and LPA unable to obtain information from W1, and LPA not able to interview R1 due to R1's medical diagnosis of R1, the allegation is unsubstantiated. Allegation: Facility improperly assisted resident (R1) with medical needs. It was alleged that R1's urine sample was sent by the facility to a different laboratory other than Pine Park Health. Review of record showed order for urinalysis. Review of facility notes, communication with Pine Park Health and FM showed that FM was informed about the urine sample. LPA interviewed the Wellness Director and S1 who stated that Pine Park has third party, Labcorp and GTI, that picks-up the urine sample. LPA tried to reach W1 but W1 did not return LPA's call. Therefore, the allegation is unsubstantiated. ...continued on 9099C (page 3) Page 3 Allegation: Staff not responding to responsible person's request for communication regarding resident's (R1) care and services. RP stated that staff S2 opened R1's mail and that FM wants to know what's going on and requested to have a meeting/discussion with former Executive Director (ED). The ED told FM she will look on it. FM had a phone conversation on January 6, 2024 regarding the issues and concerns FM brought up but never got a response/answer from former ED. LPA interviewed former ED who stated she talked to FM a lot over the phone, one was on 11/28/23 for 39 minutes, on 12/20/23 for 15 minutes, and for 16 & 20 minutes on 1/03/24. S1 also provided FM updates via phone calls and text messages. Copies of text messages, proof of phone calls obtained by LPA confirmed former ED's statements. LPA interviewed S1 who stated she communicated and provided updates to FM. S2 stated she communicated with FM via email, text & phone calls and has got into a point where FM communicated and called the staff daily. S1 also stated that they set up a weekly schedule which FM agreed, and assigned S1 and she (S2) will step up if S1 is not available to speak with FM. S2 stated that iff S1 is not available, FM will S2, the former ED and that FM also calls outside the weekly schedule. Based on information obtained, the allegation is unsubstantiated. Allegation: Staff interfere with residents' mail. It was alleged that R1's mail was opened by staff. S2 stated when she went to R1's apartment on 12/2023 to check on R1, she observed a correspondence pertaining to insurance which need to be renewed by 01/2024, so she sent the picture of the correspondence to FM which LPA obtained a copy of the text message and correspondense. S1 denied opening R1 or any of residents' mail and stated she does not have key to R1's mailbox. LPA interviewed other staff (S1, S2, S3, S4, S5, S6 and S7) who all denied opening residents' mail. AED stated not observing staff opening residents mail nor was brought to her attention. LPA also interview residents (R2 and R3) who stated their mail were never opened by staff. Therefore, the allegation is unsubstantiated. ......continued on 9099C (page 4) Page 4 Based on interviews, records review, and LPA unable to obtain information from W1 and R1, the 4 allegations are closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Jan 16, 2025 · control 15-AS-20240319155109

Type of visit: Case Management - Deficiencies

During investigation of complaint (Control # 15-AS-20240319155109), Licensing Program Analyst (LPA) was provided the following information: 1. Pine Park Health sent order to the facility to check resident's (R1) blood pressure (BP) from 02/07/2024 to 02/14/2024. Information obtained from Pine Park Health staff confirmed there's an order. However, review of R1's record and staff record sent by staff to Pine Park Health showed R1 refused blood pressure check on 02/14/2024 and BP record from 02/16/2024 to 02/19/2024. There's was no record for 02/07/2024 to 02/13/2024. LPA interviewed S1 who was not able to provide information why R1's BP was not checked for the said ordered dates. 2. R1 had overgrown toenails. Pictures obtained by LPA showed R1 had discolored overgrown toenails about 1 to 2 inches long. LPA called the podiatrist clinic who confirmed R1 was seen in 4/2024 Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction dates and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with AED.the state’s words, verbatim · CDSS document, Jan 16, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2) · Plan of correction due date: Jan 30, 2025

87465 Incidental Medical and Dental Care (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 requirement is not met as evidenced by: -Based on record review and interview, the licensee did not comply with the section in not checking R1 blood pressure as ordered on particular dates which posed a potential health risk to resident in care.the state’s words, verbatim · CDSS document, Jan 16, 2025

Plan of correction: Resident is no longer at the facility. AED to in-service the staff and submit proof by 1/30/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR1569.269(a)(6) · Plan of correction due date: Jan 30, 2025

§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers.... -This requirement is not met as evidenced by: -Based on interviews and record review, the licensee did not comply with the section above in R1 having overgrown toenails which posed a potential personal rights risk to person in care.the state’s words, verbatim · CDSS document, Jan 16, 2025

Plan of correction: Resident is no longer at the facility. AED to in-service the staff and submit proof by 1/30/25.

Allegation investigated: Staff not ensuring resident's room is clean and not keeping the facility free of insects.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Associate Executive Director (AED) Rosana Frias and informed the reason for visit. LPA obtained copy of resident roster and inspected four residents' apartments. LPA also interviewed residents (R1, R2 and R3), resident's family member (FM), staff (S1, S2, AED), witness (W1). R1, R2, FM, S1 and S2 all stated observing roaches. R3 stated observing roaches in her apartment a while ago and recently observed and killed a bug in her apartment. FM stated observing roaches in the residents' apartment and the apartment is filthy and that the staff are not making sure that the apartment is kept clean. FM further stated that roach traps had been sitting in the residents' kitchen counter for months. .....continued on 9099C Substantiated During inspection, LPA observed roach traps with dead roaches in 2 residents apartments. LPA also observed dead roach in the kitchen cabinet in 1 of the apartments and stained carpet flooring and mattress leaning on the wall in this apartment, and another apartment with litter. Based on interviews and observation, the preponderance of evidence has been met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. A $250.00 civil penalty is assessed for repeat violation of section 87303(a) within 12 month period. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty. Deficiency and plan and proof of correction were discuss with AED. Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Dec 5, 2024 · control 15-AS-20241127165044

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 19, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. -This requirement is not met as evidenced by: -Based on interviews and observation, the licensee did not comply with the section above in residents aparments not kept cleaned and free of insects which pose a potential health, safety and personal rights risks to persons in care. This is a repeat vioationthe state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: AED stated she'll do the following and submit proof by 12/19/24. 1. Have the apartments cleaned. 2. Have the pest control company come once a week . 3. Come up with a plan of ensuring the insects are eradicated completely. A $250.00 is assessed.

Allegation investigated: Non-medical staff members administering injections.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation and deliver the findings for the above allegation. LPA met with Associate Executive Director (AED) Rosana Frias and informed the reason for visit. During the course of investigation, LPA obtained copies of resident roster and staff schedule. LPA reviewed residents records and obtained copies of LIC602A Physician Report. LPA interviewed 5 residents (R1, R2, R3, R4, R5) on 2/29/24. Three (3) out of these 5 residents stated the med-tech administers insulin. LPA reviewed 4 residents records which showed 2 of these 4 residents unable to perform their own glucose testing and injections. The other 2 residents are able to perform glucose testing and administer own insulin. .....continued on 9099C Substantiated LPA interviewed 7 staff. One of these staff stated she does not administer injection; however, when she told the resident that this resident needs to do it herself, this resident told her that the other med-tech does it. One of the med-techs stated she's not a medical professional nor an LVN but she pricks for glucose tests and administers insulin to 3 residents. Based on interviews and records review, the preponderance of evidence has been met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date may result in civil penalty. Deficiency and plan and proof of corrections were discuss with AED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Dec 5, 2024 · control 15-AS-20240222115320

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87628(a) · Plan of correction due date: Dec 19, 2024

87628 Diabetes : (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through .. ..injection, or has it administered by an appropriately skilled professional. -This requirement is not met as evidenced by: -Based on records review and interviews, the licensee did not comply with the section above in having non-medical staff administers insulin injection to residents,the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: AED to do the following and submit proof by 12/19/24: 1. Have all residents records reviewed to deternine who need assistance with injections and have the LVNs perform the injections. 2. Ensure there's LVN scheduled to work during the time injections are to be performed and submit a copy of LIC500 Personnel Report.

Allegation investigated: Facility failed to supervise resident (R1) resulting to intoxication.

On this day, September 26, 2024, Licensing Program Analyst Delmundo (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with Associate Executive Director (AED) Rosana Frias, and informed of the reason for visit. It was alleged that resident (R1) was seen at the hospital on 1/14/2023 after an unwitnessed fall. The doctor noted, "fall occurred in setting of alcohol intoxication”. During investigation, LPA obtained copies of resident roster and staff schedule, and conducted interviews. LPA also obtained copies of R1’s following documents: LIC601 Identification and Emergency Contact Information; LIC602A Physician’s Report; facility notes; Hospital Discharge Summary; Letter of Conservatorship; email from conservator; Alcohol Intake Record; Unusual Incident Report (UIR). ...continued on 9099C Substantiated UIR indicated that at 1:30 am on 1/14/23, R1 was found on the floor of his room, was breathing but unable to be awaken. 9-1-1 was called and R1 was transported to the hospital. Hospital Discharge Summary showed diagnosis of alcohol intoxication among others with alcohol level of 244 on arrival, and that R1 stated he drinks ‘too much’ Vodka. On 1/19/23, LPA interviewed staff (S1 and S2) and R1’s current conservator (C1). S2 confirmed the incident happened on 1/14/23. S1 stated R1 is allowed 1 drink of travel size of Vodka of about 2 oz/day, but it doesn’t mean R1 will not ask for more and if not given, R1 will become belligerent. C1 stated that when he visited R1 one morning, C1 observed a stain in the carpet in R1’s room on which the staff stated that it’s alcohol. Review of records showed R1’s former conservator (C2) gave permission to the facility to purchase Vodka, not to give all at once and only let R1 consume 1 small bottle at night only. Facility's Alcohol Intake Records for R1 showed R1 was given from 2 to 3 times in the evening of which each time R1 was given 2 to 4 cups of 5 oz/cup. Records also showed there were days when R1 was given 5 oz at 1:00 am, 1:20 am, 1:30 am, 2:30 am and on those days, R1 was also given at night. Based on information gathered, the preponderance of evidence is met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the AED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided. UIR indicated that at 1:30 am on 1/14/23, R1 was found on the floor of his room, was breathing but unable to be awaken. 9-1-1 was called and R1 was transported to the hospital. On 1/19/23, LPA interviewed staff (S2) who confirmed the incident that happened on 1/14/23. Review of LIC602A Physician’s Report revealed R1 does not need assistance with feeding. LPA was unable to interview R1. Based on all information obtained and due to LPA was not able to obtain information from R1, the allegation is unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 15-AS-20230117150311

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.269(a)(16) · Plan of correction due date: Oct 10, 2024

§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (16) To reasonable accommodation of individual needs and preferences in all aspects of life in the facility, except when the health or safety of the individual or other residents would be endangered. -This requirement is not met as evidenced by: -Based on interviews and records review, the licensee did not comply with the section above in giving the resident alcohol more that the permitted amount.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: R1 is no longer at the facility. Executive Director to in-service the staff and submit proof by 10/10/24.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alicia Delmundo conducted an unannounced annual required inspection. LPA met with Associate Executive Director (AED) Rosana Frias, and informed the reason for visit. Facility is a seven story building, the 2nd, 3rd, 4th and 5th floors of which houses assisted living residents. Facility has LIC9282 Infection Control Plan, and updated copy provided to LPA on this same day. LPA inspected the facility inside and out with AED. LPA inspected the common areas, activity rooms, kitchen, dining rooms, Life Enhancement area, lounge/bistro. theater, fitness center/room, courtyard and back patio. Salon, housekeeping supplies room, massage/therapy rooms on the first floor were inspected. Electrical and housekeeping supplies rooms, laundry rooms on other floors were checked. Food supplies were observed good for 7 days of non perishables and 2 days of perishables. Freezers and refrigerators temperatures are checked by kitchen staff and records kept and observed within Regulations range. LPA randomly selected 10 residents rooms for inspection - 4 rooms on 2nd floor, 2 rooms on the 3rd floor, and 3 rooms each on 4th and 5th floors. Facility has carbon monoxide and smoke detectors that are in operating condition. Hot water temperature in one of the residents' bathroom on the 3rd floor was checked and measured at 114.6 degrees Fahrenheit. Fire extinguisher in the kitchen was observed fully charge with tag showed serviced April 4, 2024. Facility has evacuation chairs on stairwells. Facility conducts disaster drills and records showed last conducted August 26, 2024. LPA reviewed 5 staff and 6 residents files, and interviewed 4 residents. ....continued on 809C LPA observed the following: -at 1:44 pm, razor, hair developer, perming agent, waving lotion, anti fungal wash and screw driver in unlocked drawers in unlocked salon. -at 2:09 pm, Peritoneal cleanser in the resident's room in Memory Care Unit. -at 2:37 pm, stained/soiled carpet flooring in resident's room on the 3rd floor. -at 2:40 pm, resident (R3) has medications in the bathroom. R3's LIC602A indicated dementia. LPA verified, and per Wellness Director, R3 is on facility's Medication Program. -at 2:57 pm, cleaning supplies in unlocked housekeeping room on the 5th floor. -at 3:05 pm, stained/soiled carpet flooring in resident's room on the 5th floor. -at 4:45 pm, staff (S3) does not have the 20 total hours of required training for 2023. -at 5:20, staff (S1 and S5) has not completed the required 40 hours of training. S5 has not completed the required total initial hours of medication training. -at 6:00 pm, residents (R2 and R4) has postural support (halo; half bed rails) but no doctor's orders on file. The following updated/current documents to be submitted by October 10, 2024: 1. LIC308 Designation of Facility Responsibility 2, LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. $3M Liability Insurance certificate Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $250.00 civil penalty is assessed for repeat violation of section 87309(a) within 12 month period. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty. Deficiencies and plan and proof of corrections were discuss with AED. Due to time constraint, LPA will come back to continue inspection. Exit interview conducted. Appeal Rights, LIC421FC Civil Penaly Assessment, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Sep 26, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit in response to the Unusual Incident Report (UIR) submitted by the facility. UIR indicated that at 12:26 p.m. on February 8, 2024, Reflections Coordinator (S1) was notified by care manager (staff) that there were discrepancies with residents' narcotic medications. After S1 confirmed that the medications in the containers were incorrect, S1 reported to the Wellness Director (WD) who in turn reported to Executive Direction (KED) Cayia Henry. WD and ED immediately launched an investigation and in-service on narcotic count and recognition initiated to all med-techs. ED notified Local Law Enforcement, and Controlled Substance Count documented. On this day, March 22, 2024, LPA conducted interview and obtained copies of documents. No deficiency cited. Exit interview conducted, and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 22, 2024

Allegation investigated: -Facility is isolating residents. -Facility is delivering residents meals cold. -Facility is not providing activities for residents.

On this day, February 15, 2024, Licensing Program Analyst Delmundo (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Executive Director Cayia Henry, and informed the reason for visit. During the course of investigation, LPA obtained copies of resident roster and staff schedule. On 2/25/22,. LPA interviewed staff (S1) and 3 residents. LPA also reviewed the facility Covid-19 cases history, spoke with Associate Executive Director (AED), and obtained information regarding Local Public Health (LPH) Nurse recommendations during the time facility had outbreak. .....continued on 9099C Unsubstantiated Allegations: -Facility is isolating residents. -Facility is not providing activities for the residents. R1 stated the facility dining and activity rooms were closed and does not understand why the facility was quarantined. The other 2 residents (R2 and R3) stated they were not bothered when dining and activity rooms were closed during the outbreak and R3 stated it is for the health and safety of everyone. Staff (S1) stated the dining and activity were closed per recommendation by Public Health. Review of information obtained from AED showed that it was the LPH recommendation to close the dining and activity room during outbreak. Allegation: Facility is delivering residents meals cold. R1 stated the food delivered to his room was cold. S1 stated that during outbreak, meals were delivered to each of the resident in their room. Some of the residents were still sleeping when meals were delivered and caregivers warm their food when residents were ready to eat. R2 stated if her food was cold, it’s not a problem as caregiver warms it. R3 stated sometimes the food was not warm but it’s not a problem because he can warm it in his microwave. Based on all information gathered, the above allegations are close as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Feb 15, 2024 · control 15-AS-20220216145850

Allegation investigated: -Facility staff do not ensure materials that pose danger are stored inaccessible to residents. -Facility staff working in the kitchen do not observe food services sanitation practices.

On this day, February 15, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with Executive Director (ED) Cayia Henry, and informed the reason for visit. LPA obtained copies of staff schedule, resident roster and Activity Schedule for the month of February. LPA conducted inspection with ED. Allegation: Facility staff do not ensure materials that pose danger are stored inaccessible to residents. During inspection, LPA observed the following: hazardous construction materials, worn furniture, used matresses in the garage; scissors and salon supplies in unlocked cabinets in unlocked salon; unlocked housekeeping room on the 4th floor where cleaning supplies are kept ......continued on 9099C (page 2) Substantiated The preponderance of evidence has been met, therefore, the allegation is substantiated. A $250.00 civil penalty is assessed for repeat violation of Regulation section # 87309(a). First and second citations were issued on 8/03/23 and 10/04/23. Allegation: Facility staff working in the kitchen do not observe food services sanitation practices. LPA observed 2 kitchen staff (KS1 and KS2), one peeling a pineapple and one doing the dishes with both with long hair not wearing hairnets. Although both staff had their hair tied back, one of the staff's hair dangling. Based on information obtained, the preponderance of evidence was met, therefore, the allegation is substantiated. Deficiencies, plan and proof of corrections and civil penalty were discussed with ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, LIC421FC Civil Assessment, and copy of this report provided. Allegation: Facility inappropriately serving alcohol to residents. List of Activities includes Happy Hour once a week. ED stated Happy Hour is open to all residents; however, not a lot of residents come. There's residents who regularly join the Happy Hour and the staff who serve during Happy Hour has list of residents who are not to be given alcohol per doctor's order. If they are not sure, they give the resident a "mock cocktail". If there's a new resident who wants alcohol. the staff check with the doctor first; this statement was observed by LPA during Happy Hour as one ot the staff informed 1 of the resident. LPA interviewed the 3 staff, 2 of which stated they only serve alcohol to those who are on the list to be given. The staff only give maximum of 2 small cups which was confirmed by LPA upon observation. LPA reviewed 1 of the resident who is on the list allowed to be given alcohol, Record showed this resident does not have order from the doctor prohibiting the resident from alcohol consumption. Allegation: Staff drinking alcohol while at the facility. It was alleged that 3 staff (S1, S2 and S3) drink alcohol when at the facility. LPA interviewed S1, S2 and S3 who all denied the allegation. LPA interviewed other 7 staff, 6 of which stated not observing S1, S2 and S3 drinking alcohol when at the facility. LPA also interviewed 1 of residents family member who stated not observing any staff drinking alcohol. Based on all information gathered, the 3 allegations are unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiency cited. Exit interview conducted, and copy of this report provided.the state’s words, verbatim · CDSS document, Feb 15, 2024 · control 15-AS-20240212095317

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Feb 17, 2024

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. -This requirement is not met at evidence by: - Based on observation, the licensee did not comply with the section above for the following which poses immediate risk to persons in care: housekeeping room and salon unlocked; hazardous materials and debris in the garage.the state’s words, verbatim · CDSS document, Feb 15, 2024

Plan of correction: ED locked the salon and housekeeping room. In addition, ED will do the following and submit proof by 2/17/24: 1. Have the garage cleaned 2. In-service the staff.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(15) · Plan of correction due date: Feb 29, 2024

87555 General Food Service Requirements: (b)(15) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination. -This requirement is not met at evidence by: -Based on observation, the licensee did not comply with the section above in 2 kitchen staff not wearing hair nets which pose potential health and/or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 15, 2024

Plan of correction: ED to in-service the staff and submit proof by 2/29/24.

Type of visit: Case Management - Incident

On this day, 12/22/2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management as a follow-up on the Death Reports and Unusual Incident Reports (UIRs) received by the Department. LPA met with Executive Director (ED) Cayia Henry, and informed the reason for visit. Reports indicated the following: 1. Resident (R1) Death Report Report indicated R1 passed away on 5/09/23 with cause of death unknown. R1 was previously sent to the hospital for increased confusion and complaints of left hip pain. R1 expired at the hospital. R1's son called the facility to inform that R1 passed away.. 2. Resident (R2) Death Report Report indicated R2 passed away on 7/17/23. R2 was found unresponsive, no pulse noted and pale in color. Med-tech on duty called 9-1-1 right away. R2 had a fall on 7/10/23 but refused to paramedics to be transferred to ER. R2 refused paramedics again on 7/12/23; was sent via 9-1-1 for an x-ray appointment on 7/14/23, but refused to stay in the hospital for treatment. R2 again refused to be sent out on 7/16/23 due to distended abdomen, 3. Resident (R3) Unusual Incident Report (UIR) UIR indicated R3 had un-witnessed fall on 12/23/23 and was noted with a bump on the side of R3's head and abrasion on the left knee. 9-1-1 was called and R3 was taken to the hospital. Family member, primary care physician and facility's Wellness Director notified. 4. Resident (R4) UIR UIR indicated R4 was seen lying on the floor screaming for help and complaining of pain of left side of leg and head. R4 was conscious and responsive. 9-1-1 was called and R2 was taken to the hospital. Family member, primary care physician and facility's Wellness Director notified. LPA reviewed residents' files and obtained copies of documents including but not limited to the following: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; Appraisal; facility notes; Post-fall Evaluation; hospital discharge documents. LPA conducted interview. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction of due dates may result in civil penalties. Deficiencies and plan and proof of correction were discussed with ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Dec 22, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Jan 5, 2024

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental,..... .....and social condition. -This requirement is not met as evidenced by: - Based on records review and interview, the licensee did not comply with the section above for not doing a re-appraisal or updating Care Plan after R1 had multiple falls in few months.the state’s words, verbatim · CDSS document, Dec 22, 2023

Plan of correction: R1 is no longer at the facility. Executive Director stated she'll have all the files double checked and ensure records are updated. Self-certification to be submitted by 1/05/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Jan 5, 2024

87211 Reporting Requirements (a)(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 event.(D)Any incident which threatens the welfare, safety or health of any resident,... -This requirement is not met as evidenced by: - Based on records review and interview, the licensee did not comply with the section above for not submitting incident report for R2 which poses a potential health, safety and/or personal rights risks to person in care,the state’s words, verbatim · CDSS document, Dec 22, 2023

Plan of correction: R2 is no longer at the facility. Executive Director stated an in-service training for the Wellness Department will be conducted to ensure enforcement of Reporting Requirements. Copy of in-service to be submitted by 1/05/23.

Type of visit: Case Management - Annual Continuation

On this day, 12/22/23, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual required inspection that was started on 10/04/23. LPA met with Executive Director (ED) Cayia Henry, and informed the reason for visit. LPA reviewed 5 residents records. LPA checked the medications and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Dec 22, 2023

Type of visit: Case Management - Incident

On this day, 12/15/2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct case management as a follow-up on the Death Report received by the Department on 12/11/23. Report indicated that when caregiver (S1) arrived at R1's apartment to assist with feeding for dinner, S1 noted that R1 was unresponsive. Med-tech (S2) was gathering vital signs and noted that there was no pulse noted. Wellness Nurse (S3) called 9-1-1 and called the closest kin. Report also indicated that R1 returned to the facility on 12/08/23 from post acute. LPA obtained copies of including but not limited to the following documents: Notice of Transfer/Discharge from post acute; LIC602A Physician's Report; LIC9172 Functional Capability Assessment dated 12/08/23; Progress Notes, LPA conducted interviews. No deficiency cited on this day, Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Dec 15, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alicia Delmundo conducted an unannounced annual required inspection. LPA met with Executive Director (ED) Cayia Henry, and informed the purpose of visit. Facility is a seven story building, 2nd, 3rd, 4th and 5th floors of which houses assisted living residents. Facility has an LIC808 Mitigation Plan on file; however, Infection Control Plan on facility file was dated January 2020, and needs updating. LPA inspected the facility inside and out with ED. LPA inspected the common areas, activity rooms, kitchen, dining rooms, courtyard and back patio. Salon, housekeeping supplies room, massage/therapy rooms on the first floor were inspected. Electrical and housekeeping supplies room on other floors and laundry room were checked and observed locked. Food supplies were observed good for 7 days of non perishables and 2 days of perishables. Freezers and refrigerators temperatures are checked by kitchen staff and records kept. LPA observed the freezer and refrigerator temperatures were at -7.0 and 35 degrees Fahrenheit respectively. LPA randomly selected 8 residents rooms for inspection - 2 each on 2nd, 3rd, 4th and 5th floors. Facility has carbon monoxide and smoke detectors and observed functional. Hot water temperature in one of the resident rooms on the 2nd floor was tested and measured at 116.8 degrees Fahrenheit. Fire extinguisher in the kitchen was observed fully charge with tag showed serviced August 28, 2023. Facility has evacuation chairs on stairwells. Facility conducts disaster drills for all shifts every quarter. and records showed last conducted September 26. 2023. LPA reviewed 5 staff files, and interviewed 4 staff and 4 residents. .......continued on 809C LPA observed the following: -at 12;05 pm, blade and scissors in the drawer without lock in unlocked salon. -at 12:10 pm, professional strength glue, scissors, paint spray, fabric and vinyl adhesive spray in cabinets without lock in unlocked art room. -staff (S2) does not have First Aid certificate. -staff (S5) does not have the required 8 hours of medication training for 2022. The following updated/current documents to be submitted by October 18, 2023: 1. LIC308 Designation of Facility Responsibility 2, LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. Infection Control Plan and Monkeypox Infection Control Plan Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $250.00 civil penalty is assessed for repeat violation of section 87309(a) within 12 month period. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty. Deficiencies and plan and proof of corrections were discuss with ED. Due to time constraint, LPA will come back to continue inspection. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Oct 4, 2023