Ivy Park at Laguna Creek

Allegation investigated: Facility did not repair broken plumbing in a timely manner. Facility did not ensure resident receives a bath/shower. Resident's room is in disrepair. Residents heater is not operating in their room.

On 08/26/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to complete and deliver the findings of the investigation into the above allegations. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator/Executive Director (ED). LPA met with ED Karen Bassi and a brief interview followed. LPA interviewed the ED, the resident, R1,the Maintanance DIrcector, and reviewed the work orders provided by the Maintenance Director. A water leak in the ceiling of R1's bathroom was reported on 12/23/25 and a work order was created at 7:53 AM. On that day, the water to the cottage was turned off, the issue was assessed and plumbers were brought in to replace a 1/2 inch copper line valve. On 12/24/25, another work order was created to have a construction crew to fix the damage from the water line in R1's bathroom by dry walling the area. This left the ceiling wet with mud which needed time to dry before finishing the repairs. On 12/25/25, maintenance worker, (M1) stated that workers returned and painted the area to complete the job. Unsubstantiated The broken water pipe and the damage it caused were repaired within a 3-day period. The Department found the allegation, "Facility did not repair broken plumbing in a timely manner," 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 allegation is UNSUBSTANTIATED. According to interviews with the ED, R1 and maintenance worker (M1), the facility offered R1 the opportunity to relocate to another room for the duration of the repairs. R1 declined. They also offered to provide R1 with access to the shower in the model room. R1 also declined that offer. The Department found the allegation, "Facility did not ensure resident receives a bath/shower," 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 allegation is UNSUBSTANTIATED. Through interviews with the ED and with R1, this LPA learned that R1 preferred things very organized and had them just the way they wanted them in their home. When urgent repairs were conducted in their bathroom, maintenance removed R1's personal items and put them outside of the bathroom so they could conduct the repairs. When they completed the work, housekeeping conducted a routine clean-up. R1 was not pleased and contacted management to have them do another cleaning. When this LPA asked what was not done by housekeeping, R1 said that everything was still all over the place and that they had not returned R1's personal items to their original locations. Some hygiene items were returned to the bathroom and others were still in R1's living area and not where they were supposed to be. LPA asked if the sink area, toilet, tub/shower and floors were clean. R1 said yes, they were, although "it was a bit dusty behind the toilet". The facility sent housekeeping in twice in an attempt to meet R1's standards. Regarding the allegation, "Resident's room is in disrepair," the Department found the allegation 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 allegation is UNSUBSTANTIATED. LPA interviewed the ED, M1, R1 and reviewed a work order dated 12/29/25. This LPA learned that on 12/29/25, a work order was created at 8:49 AM. According to the work order, by 9:40 AM the problem had been resolved. The notes on the work order read," PTAC unit keeps tripping the main breaker. Was able to finally reset breakers. Unit is working at this time. Ordering another PTAC unit for this unit just in case unit keeps malfunctioning." Regarding the allegation, "Residents heater is not operating in their room," The Department found the allegation to be 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 allegation is UNSUBSTANTIATED. LPA conducted a brief tour while at the facility. LPA observed that there was a Tour being conducted for potential residents. LPA also observed a group of 6 residents preparing to go on an outing to the Aviator Cafe. According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. A copy of this report was provided and an exit interview was conducted with Bassi.the state’s words, verbatim · CDSS document, Aug 26, 2026 · control 27-AS-20251231100403

Allegation investigated: Staff not present/available in a timely manner to meet resident(s) care needs.

On 07/20/2026, Licensing Program Analyst (LPA) arrived unannounced to this facility to conduct a complaint visit. LPA met with the administrator Karan Bassi and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegation above. The current census is 87. Allegation: Staff not present/available in a timely manner to assist emergency personnel with resident information during emergencies. It was alleged that staff did not present resident information in a timely manner to assist during emergencies. This investigation consisted of interviews with facility staff, facility observation and records review. 06/01/2026, LPA Hughes conducted a visit to the facility and spoke with the Health Services Director, who stated that caregivers and medication technicians are trained to respond to emergency calls and situations. It was further stated that the facility is in the process of relocating resident records and prior to the relocation, staff were unaware of where resident information was stored and how to respond during emergencies. Continuation 9099-C Substantiated LPA toured the facility, and observed 911 health packets containing resident identification, medication lists, allergies, primary diagnosis, and DNR notifications. However, LPA observed that only 3 of the facility’s 14 resident rooms contained emergency health packets. Additionally, LPA reviewed resident records and observed that resident files were incomplete and disorganized, which could delay staff’s ability to provide emergency personnel with necessary resident information in a timely manner during an emergency. This was observed not in compliance with Title 22 regulation 87506(a) as the facility did not ensure resident records were complete, organized, and readily available to facility staff during emergencies. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility.the state’s words, verbatim · CDSS document, Jul 20, 2026 · control 27-AS-20260528140537

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Jul 22, 2026

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by: The facility did not ensure that resident records were complete, organized, and readily available to facility staff during emergencies.the state’s words, verbatim · CDSS document, Jul 20, 2026

Plan of correction: The facility stated that a plan has been implemented to ensure that resident records are readily available for facility staff to assist emergency personnel in any event of emergency.

Type of visit: Required - 1 Year

On 07/20/2026, Licensing Program Analyst (LPA) Shakaricka Hughes arrived at the facility to conduct an unannounced annual inspection. LPA Hughes met with the Executive Director/ Administrator Karan Bassi, and the Health Services Director Jordan Raymundi who assisted LPA during today's visit. The current census is 87 with 15 facility staff present. This facility is a single story building licensed to serve (88) non-ambulatory and (20) bedridden residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 113.9 degrees Fahrenheit in four (4) resident bathroom sinks, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. LPA observed fire extinguishers located in each cottage last serviced on 11/12/2025. LPA observed public telephones located in the med rooms of each cottage, and the facility has the required posters posted. Facility thermostat was observed at 71 degrees Fahrenheit. LPA observed toxins located in a locked storage inaccessible to residents. LPA observed sharp knives kept, locked in the kitchen and inaccessible to residents. Continuation 809-C LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 6 residents medications and the medication administration record (MAR) was complete. The first aid kit was checked and contained the required components. LPA requested resident and staff files for review. LPA reviewed 10 resident files and they were complete. LPA reviewed 5 staff files, and it was complete. LPA reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared. The following documents will be email to LPA by 07/21/2026: (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (3) LIC 610 Current Emergency Disaster Plan (4) Proof of Current Liability Insurance (5) LIC 500 Current Personnel Report As a result of this annual visit, the facility is in compliance with Title 22 Regulations, and a copy of these LIC 809 report were provided to the facility.the state’s words, verbatim · CDSS document, Jul 20, 2026

Type of visit: Case Management - Incident

On 07/01/2026 Licensing Program Analyst (LPA) Shakaricka Hughes conducted an unannounced visit to the facility. The purpose of the visit was to follow up on an incident report that was submitted to the Dept on 06/27/2026. LPA met with the Memory Care Director, Olivia Prince. The current census is 89 with 12 facility staff present. LPA interviewed Olivia regarding an incident that occurred on 06/07/2026 in the Memory Care Unit, involving facility staff (S2). According to the incident report, S2 attempted to prevent a resident from leaving the Memory Care Unit and exiting the facility. Facility staff (S1) reported witnessing (S2) strike the resident across the face and then escorted the resident back to their room. Olivia stated that, following the incident, the facility conducted several in-service training courses, including Mandated Reporting training on 06/24/2026. LPA reviewed personnel records for (S1) and observed documentation verifying completion of Acknowledging Requirement to Report Suspected Abuse on 01/19/2026. Despite having received the required training, S1 failed to immediately report witnessing the alleged physical abuse of a resident by staff (S2), as required. Based on today's case management, a citation is issued under Title 22, Division 6. An exit interview was conducted and a copy of this report LIC 809, LIC 809-D and appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Jul 1, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Jul 2, 2026

87211 Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met as evidenced by: Based on interview and record review, the facility did not ensure the reporting of an alleged event involving a staff member slapping a resident. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2026

Plan of correction: The facility will read Title 22 regulation 87211 and submit a signed acknowledgment of understanding the regulation to LPA by 07/02/2026 via email.

Allegation investigated: Resident was sexually abused while in care.

On 2-3-2026 at 10:15am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation, and to deliver and discuss findings regarding the allegation noted above. LPA met with Administrator Karin Bassi and explained the purpose of the visit. During this investigation, the Department conducted interviews with three residents, three staff members and one additional witness. LPA also reviewed facility file documentation including physician’s report, and individualized service plan pertaining to resident1 (R1). Additionally, LPA reviewed a police report pertaining to the above allegation, and hospital discharge paperwork. Allegation: Resident was sexually abused while in care. Based on interviews and record reviews it was revealed that on or about 10/16/2025 R1 was sent to a local hospital with symptoms of illness and sore throat. While at the hospital R1 was evaluated and bruising was noted on the vaginal area, and appropriate parties were contacted to report possible sexual abuse. {Cont. on 9099C} Unsubstantiated After an additional evaluation, it was revealed that there were no signs of sexual or other abuse. Police report reviewed contained additional interviews and outside agency consultation which revealed no indication or substantiated evidence of sexual abuse. Interviews conducted and other documentation reviewed did not reveal any corroborated statements or evidence to suggest sexual abuse occurred while in care. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator, and a copy of this report was provided. Appeal rights and LIC 811 provided.the state’s words, verbatim · CDSS document, Feb 3, 2026 · control 27-AS-20251020160415

Allegation investigated: Staff did not allow resident access to bedroom Staff do not safeguard residents' confidential information

Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to open this complaint investigation. LPA Moleski met with administrator Karan Bassi and explained the purpose of the visit. This investigation consisted of record review, interviews, and observation. In an interview, Bassi said that a resident (R1) was moved out of their room in Dogwood Cottage, D3, in the facility's memory care area, on September 25 to a room in Cedar Cottage, C2, in the facility's assisted living area. The facility's memory care director (S1) said that they had been instructed to identify two memory care residents who may be appropriate to move into assisted living due to new prospective residents seeking memory care placements. R1 was one of these residents, and R2 was another. Both Bassi and S1 said that R1's responsible party asked to return R1 to memory care after a short period of time. [continued on 9099-C] Substantiated Bassi said that R1 was moved back to memory care on October 1, but R1 could not return to their original room, D3, because another prospective client had already placed a deposit on the room. R1 was moved to room D7, according to Bassi. LPA Moleski spoke with R1's responsible party over the phone, who declined to answer questions. In an interview, R1 said they had been recently moved, but that they preferred their original room to their new room and and that they did not know why they were moved. LPA Moleski reviewed R1's and R2's files. LPA Moleski observed that R1 had only one admission agreement on file, dated April 30, 2024. The admission agreement specifies R1's room as room D3. The admission agreement states, in part, that "[R1] may live in [their] room on a month-to-month basis..." The admission agreement does include sections which clarify expectations in the event of room transfers, as well as termination conditions. Page 7 of R1's admission agreement states that "Ivy Park may need to substitute your apartment with another apartment ... for any ... reasonable purpose, as determined by the executive director of the community ... upon a thirty (30) day notice. A request by you for an apartment substitution will be granted in Ivy Park manager's discretion." 22 CCR Section 87507(c-d) requires all attachments or modifications made to admission agreements to be signed and dated. LPA Moleski requested all modifications to R1's admission agreement. Bassi provided LPA Moleski an apartment transfer form for R1, indicating that R1 was moved from room C2 to D7 as of October 1. The form was not signed by facility representatives, the resident, or the resident's responsible party. Page 8 of R1's admission agreement indicates that their contract may be terminated by the resident "at any time, with or without cause, by giving the executive director of the community ... thirty (30) days prior written notice of termination." Licensee-initiated termination of contract is outlined by 22 CCR Section 87224, which requires under most circumstances a 30-day notice. The termination conditions outlined in the admission agreement do not indicate that, by moving into a different room, R1's contract was automatically terminated. R1 was not required to have a new admission agreement signed for their stay in room C2 between Sept. 25 and Oct. 1. 22 CCR Section 87507(c) requires a new admission agreement seven days after admission, and R1 was in room C2 for only six days, according to Bassi. However, in lieu of any signed and dated modifications, formal termination with applicable written notice, or an entirely new signed and dated admission agreement for their new room, R1's contract remained in effect as originally agreed upon, meaning that R1 should have retained the right to return their original room, D3. [continued on 9099-C] LPA Moleski reviewed the file of the resident who currently resides in room D3 (R3). LPA Moleski observed a signed admission agreement permitting R3 to live in room D3. The admission agreement was dated September 27, just two days after R1 left room D3. LPA Moleski reviewed a payment authorization form and a community fee receipt for R3, both signed and dated Sept. 27. LPA Moleski did not observe a current admission agreement for R1 for their new room, D7. According to Bassi and S1, R2 was moved out of room D7 into room C2, in order to permit R1 to return to their initial memory care cottage. LPA Moleski reviewed R2's file and observed no admission agreements on file. Bassi said R2's initial admission agreement was written under the previous management company. LPA Moleski was provided two apartment transfer forms for R2. One indicated that R2 was to be moved from room D7 to room C2, however, this form was not signed. The second indicated that R2 was to be moved from room D7 to room C5. This version was signed by R2's responsible party, and by a facility representative, and was dated Sept. 26. However, as of today's visit, R2 is living in room C2, not room C5, as the signed and dated modification states. R2 had no current signed and dated admission agreement on file regarding their present residency in room C2. During a tour of Cedar cottage, LPAs Moleski and Lindstrom observed an office area in the cottage unattended. LPAs Moleski and Lindstrom observed several binders left lying on a desk area, despite the presence of locking cabinets directly above the desk. LPAs Moleski and Lindstrom observed multiple documents containing confidential resident information present in these binders, including residents' diagnoses, care plans, care notes, prescription information, medical information, and other personal identifying information. There was not a staff member in the immediate vicinity when LPAs Moleski and Lindstrom began inspecting the area. LPAs Moleski and Lindstrom did, however, observe residents and at least one visitor walking by during their inspection of the records. The department has determined the following as it relates to the allegations that staff did not allow a resident access to their bedroom and that staff do not safeguard residents' confidential information: Based on interviews and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Sections 87507(f) and 87506(c)(1) An exit interview was held with Bassi. A copy of this report and appeal rights were left with Bassi.the state’s words, verbatim · CDSS document, Oct 16, 2025 · control 27-AS-20251014081930

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Oct 24, 2025

"(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments." This requirement was not met as evidenced by: Based on record review and interview, all terms and conditions of residents' admission agreements and/or modifications were not adhered to, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Oct 16, 2025

Plan of correction: Licensee agrees to provide LPA Moleski with updated admissions documents for R1 and R2 by POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c)(1) · Plan of correction due date: Oct 24, 2025

"(c) All information and records obtained from or regarding residents shall be confidential ... (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents..." This requirement was not met as evidenced by: Based on observation, confidential resident records were not stored or safeguarded in a manner which protected their confidentiality, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Oct 16, 2025

Plan of correction: Licensee agrees to provide LPA Moleski with inservice training records regarding safeguarding confidential records by POC due date. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator James Dial and explained the purpose of the visit. LPA Moleski reviewed an incident report dated 9/23/25. According to the incident report, a resident (R1) was found lying on the floor of their room on 9/21/25 covered in feces after an apparent fall. R1 told responding staff that they had gotten dizzy and fell while on their way to the restroom, according to the incident report. LPA Moleski interviewed R1, who did not remember details relating to the incident. However, R1 said that they do sometimes experience dizziness while standing. R1 also said that staff are responsive when they need assistance. LPA Moleski interviewed the medication technician who found R1 after their fall (S1) and the caregiver who assisted afterward (S2). S1 said they had gone to R1's room for a routine medication pass. S1 said that R1 told them they had been on the ground for about 10 minutes. S2 said they were alerted to R1's condition shortly after starting their shift around 7 a.m. Both S1 and S2 said they were not sure how long R1 had been on the floor, but both said the feces on R1 was not dry. S1, S2, and S3, the facility's health services director, said that R1 does not use their call button when assistance is needed. S1-S3 said that R1 did not use their call button after their fall on 9/21/25. LPA Moleski reviewed R1's file. R1's LIC 602 dated 5/5/25 indicates a diagnosis of dementia. R1's needs and services plan, dated 3/22/25, does not indicate R1 requires additional status checks beyond routine care tasks. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Dial.the state’s words, verbatim · CDSS document, Sep 30, 2025

Allegation investigated: Illegal eviction Medications were not provided to resident as needed

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with facility administrator James Dial and explained the purpose of the visit. This investigation consisted of interviews and record review. LPA Moleski interviewed three facility staff members (Dial, S1, S2), a former resident of this facility (R1) and that resident's responsible party (R1's RP). LPA Moleski reviewed R1's file, including all medication administration records (MARs) and medication orders. R1 moved into this facility on June 2, 2025, and moved out on June 13, 2025. Based on interviews with staff and with R1's RP, there was no written notice regarding R1's move-out, and all conversations regarding the move-out were verbal. [continued on 9099-C] Unsubstantiated Based on interviews with staff, R1 wandered from their delayed-egress cottage on at least one occasion, and frequently attempted to elope after that. Charting notes regarding R1 indicate that on 6/3/25, R1 wandered "on to the streets," with staff following to supervise R1. After this and other incidents, Dial said R1's RP was "required" to acquire third-party one-on-one caregivers to supervise R1 during certain hours. This issue will be addressed in a separate case management report. In an interview, Dial said that R1 was not a good fit for the facility due to the open cottage-style layout, and R1 would be better served by a more secure facility. Dial said he did explain this to R1's RP, but he never told R1's RP that R1 needed to leave. In an interview, R1's RP did not describe R1's move-out as an eviction, and R1's RP complimented facility staff. R1's RP said that Dial did explain that R1 was "not a good fit" at this facility. R1's RP said they asked Dial what their options were, and Dial gave a preferred timeline for move-out, however this was described by R1's RP as Dial's preference, and not a requirement. In an interview, R1's RP did raise concerns regarding two of R1's medications, a certain depressant and a certain antipsychotic. LPA Moleski reviewed R1's medication list from their previous skilled nursing placement, dated 6/2/25, and a medication clarification signed by R1's physician dated 5/31/25. LPA Moleski observed on each an order for R1 to take the antipsychotic twice daily and an order for R1 to take the depressant as needed every six hours. No additional orders for either medication were included in these records. LPA Moleski reviewed R1's MARs and observed that these orders were listed as described. LPA Moleski further observed that these medications were administered as ordered during the duration of R1's stay at this facility. The department has determined the following as it relates to the allegations that a resident was illegally evicted and that medications were not provided to resident as needed: Based on interviews and record review, the above allegations are UNSUBSTANTIATED, which 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 deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Dial.the state’s words, verbatim · CDSS document, Sep 3, 2025 · control 27-AS-20250617103041

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on a complaint investigation. However, during the course of that complaint investigation, LPA Moleski discovered an unrelated deficiency. LPA Moleski met with facility administrator James Dial and explained the purpose of the visit. During the investigation of complaint #27-AS-20250617103041, LPA Moleski interviewed Dial and a former resident's responsible party (R1's RP). Admission documents for R1 indicate that R1's RP was appointed R1's attorney-in-fact. R1 moved into this facility on 6/2/25 and moved out on 6/13/25. An allegation on complaint #27-AS-20250617103041 was that R1 was illegally evicted. This allegation was determined to be unsubstantiated. Based on interviews with staff, there was no formal notice to evict and no other written communication on the topic of R1's move-out, merely verbal conversations. During an interview, facility staff (S1) stated that R1 was provided with one-on-one caregivers through an outside agency in order to supervise R1 during certain hours prior to R1's move-out. Facility staff (S1 and S2) voiced concerns over R1's tendency to seek exits and continued attempts to elope. In an interview on 7/8/25, Dial said "we required [R1's RP] to get one-on-one" supervision. LPA Moleski asked specifically if R1's RP was "required" to acquire these third party services. Dial reaffirmed that R1's RP was required to do so. In an interview, R1's RP also stated that it was a "requirement" that one-on-one supervision be provided through a third-party prior to R1's departure from the facility. R1's RP said they paid "out of pocket" for these one-on-one caregivers for three or four nights. [continued on 809-C] Per 22 CCR Section 87468.1(a)(16), residents in all facilities have the right to "reject ... services." If additional care and supervision over a resident is necessary, facilities have the right to charge for additional in-house care costs per HSC Section 1569.657, but this requires an itemized bill and written notice at a minimum. Additionally, per 22 CCR Section 87464, care and supervision are basic services which must be provided by a licensed care facility to each resident. 22 CCR Section 87411(a) requires that staff be "sufficient in numbers ... necessary to meet resident needs." This facility is hereby cited per 22 CCR Section 87468.1(a)(16). An exit interview was held with Dial. Appeal rights and a copy of this report were left with Dial.the state’s words, verbatim · CDSS document, Sep 3, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Sep 4, 2025

"(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: ... (16) To receive or reject medical care or other services." This requirement was not met as evidenced by: Based on interviews, facility staff "required" a resident's attorney-in-fact to acquire and pay for third-party one-on-one caregivers, which poses an immediate personal rights risk.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Licensee agrees to review the sections referenced in this report and to write a signed statement acknowledging that residents, and by extension their designated attorneys-in-fact, cannot be required to acquire third-party care or supervision services, by POC due date. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator James Dial and explained the purpose of the visit. LPA Moleski received an incident report from this facility on 6/24/25. LPA Moleski previously discussed the incident report with staff on 7/8/25. However, due to time constraints, LPA Moleski was unable to complete a case management visit regarding this incident at that time. The incident report described above states that a resident (R1) was discovered missing around 7:20 p.m. on 6/23/25. R1 lives in a delayed-egress memory care cottage equipped with door alarms. The incident report stated that staff searched the cottage, but could not find R1. Staff continued to search the surrounding areas, and R1 was found in a nearby parking lot off facility property around 7:45 p.m., according to the incident report. LPA Moleski spoke with R1 during his visit on 7/8/25. R1 did not remember the incident. LPA Moleski reviewed R1's LIC 602, dated 5/23/25, and observed that R1 has a diagnosis of mild cognitive impairment and has a history of seizures. R1 is not permitted to leave the facility unassisted, according to their LIC 602. R1 suffers from confusion and has an unsteady gait, according to the LIC 602. R1 is nonambulatory, per the 602. R1's pre-admission appraisal, dated 6/11/25, indicates that R1 needs special observation and/or night supervision due confusion, forgetfulness, and/or wandering. R1's LIC 602 addendum, dated 5/23/25, indicates that R1 suffers from hallucinations. [continued on 809-C] LPA Moleski interviewed the cottage's on-duty caregiver (S1) during his visit on 7/8/25 and also on 9/3/25. S1 said that they were sitting near the front doors of the cottage prior to R1 being discovered missing. However, S1 said they heard no alarms, and did not see R1 leave. 22 CCR Section 87705(e)(5) requires that "facility staff shall ensure the continued safety of residents [with a dementia diagnosis] if they wander away from the facility..." Additionally, HSC Section 1569.312(d) requires that staff remain "aware of the resident's general whereabouts..." at all times. This facility is hereby cited per HSC Section 1569.312(d). As this deficiency involves an absence of supervision, an immediate civil penalty in the amount of $500 is hereby assessed. An exit interview was held with Dial. Appeal rights and a copy of this report were left with Dial.the state’s words, verbatim · CDSS document, Sep 3, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(d) · Plan of correction due date: Sep 4, 2025

"Every facility required to be licensed under this chapter shall provide at least the following basic services: ... (d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. " This requirement was not met as evidenced by: Based on interview and record review, facility staff were unaware of R1's general whereabouts for at least 25 minutes, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Licensee has already conducted staff training regarding elopement protocol. Licensee further agrees to provide LPA Moleski with a copy of training sign-in sheets by POC due dates. vincent.moleski@dss.ca.gov

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator James Dial and explained the purpose of the visit. LPA Moleski reviewed five resident files (R1-R5) and five staff files (S1-S5). LPA Moleski reviewed R1's file. R1's LIC 602 was dated 6/21/25. R1's move-in date was recorded as 7/28/25. R1's LIC 602 indicated that R1 had a pressure injury, but it was not staged. R1's LIC 602 indicated that R1 did not have home health services. In an interview, the facility's health services director (S6) said that they were not aware R1 had a pressure injury upon admission. An assessment for R1 dated 7/27/25 indicated that R1 did not have any wounds or bedsores. Dial said he received R1's LIC 602 from R1's previous placement on 7/25/25. LPA Moleski reviewed ongoing notes for R1. An "open area" was identified on R1's heel on 7/29/25, according to a note written on that same date. On 8/3/25, a "worsening condition of wound on left heel" was noted. The "top skin layer came off," and was "oozing and bleeding," according to the note. An incident report from 8/3/25 indicated that R1 was sent to the hospital, and S6 "started the process of obtaining a referral for home health" on that date. S6 said that R1 received no wound care at the facility prior to 8/7/25, when home health personnel visited for the first time. S6 said that they would have been able to secure a referral for home health prior to R1's admission if they were aware that R1 had a wound. [continued on 809-C] LPA Moleski reviewed R5's file and observed an LIC 602 dated 2/9/2022, and a second LIC 602 dated 8/1/2023. LPA Moleski asked for documentation of a routine annual visit within the last year. LPA Moleski was provided after-visit summaries for R5 from emergency room visits in December 2024 and April 2025 for confusion resulting from a UTI and a fall, respectively. Neither of these constitute routine annual visits evaluating general health. LPA Moleski toured the facility with Dial and inspected common areas, kitchen areas, bedrooms, bathrooms, and outdoor areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 109 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. During LPA Moleski's tour, LPA Moleski and Dial observed a bottle of degreaser left unattended outside. LPA Moleski and Dial also observed that the facility maintenance director's office was unlocked. The office, which has a primary entryway leading from the common outdoor area, contained multiple cleaning solutions and potentially hazardous tools. In two separate memory care cottages, LPA Moleski and Dial observed lime scale remover and isopropyl alcohol left in unlocked cabinets, respectively. LPA Moleski and Dial observed on the floor of a memory care cottage medication room one tablet of medication and one half of a medication capsule shell. LPA Moleski observed first aid supplies, fully-charged and up-to-date fire extinguishers, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed locked carts used for the storage of medication. LPA Moleski interviewed two staff members (S7-S8) and three residents (R4, R6-R7). This facility is hereby cited per 22 CCR Sections 87631(a)(1), 87309(a), 87465(h)(5), and 87463(h)(1). An exit interview was held with Dial. Appeal rights and a copy of this report were left with Dial.the state’s words, verbatim · CDSS document, Aug 14, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator James Dial and explained the purpose of the visit. LPA Moleski reviewed an internal incident report which was provided by facility staff on 06/20/25 during a complaint investigation visit. The internal incident report described a resident (R1) engaged in "hazardous wandering" on 6/3/25. According to the internal incident report, R1 was supervised, but had left the community. Dial said R1 was walking along the sidewalk with staff, and 911 was called as a result because R1 was not redirectable. R1 has a diagnosis of dementia and suffers from confusion and wandering behaviors, according to R1's LIC 602, which is dated 5/31/25. LPA Moleski reviewed CCLD fax and email records and observed no incident report was received regarding this incident. The facility's resident care coordinator (S1) said an incident report was not submitted to CCLD regarding this incident. Dial agreed that an incident report should have been submitted regarding this incident. Dial said there was a second incident on 6/7/25 wherein R1 left their cottage, but did not leave the facility grounds. LPA Moleski asked Dial to provide the internal incident report from this second incident when possible. Dial agreed to do so. This facility is hereby cited per 22 CCR Section 87211(a)(1)(D). An exit interview was held with Dial. Appeal rights and a copy of this report were left with Dial.the state’s words, verbatim · CDSS document, Jul 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jul 11, 2025

"(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below ... Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident." This requirement was not met as evidenced by: Based on interview and record review, an incident which threatened R1's health, safety, and/or welfare was not reported to CCLD, which poses a potential health, safety and/or personal rights risk.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: Licensee agrees to submit to LPA Moleski a written acknowledgement that reporting requirements have been reviewed and will be adhered to in the future. vincent.moleski@dss.ca.gov

Allegation investigated: Facility has insufficient staffing to meet resident needs

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator James Dial and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. LPA Moleski conducted interviews with 15 staff members (S1-S15) and seven residents (R1-R7). LPA Moleski toured each cottage serving residents of facility on 11/21/24. LPA Moleski observed each cottage serving residents had at least two staff members present in the building. At the time, there were between eight and 14 residents in each cottage, two of which were for assisted living residents (Aspen and Birch) and three of which were for memory care residents (Dogwood, Elm and Fir). [continued on 9099-C] Unsubstantiated LPA Moleski reviewed staffing schedules for assisted living and observed that at least two caregivers were regularly scheduled for each cottage during morning and afternoon shifts, with one medication technician scheduled per shift to cover the two assisted living cottages. One caregiver was always scheduled for each cottage for each night shift. LPA Moleski reviewed staffing schedules for memory care and observed that two caregivers were regularly scheduled to work in each cottage for morning and afternoon shifts. On some days out of the week, one medication technician/caregiver was scheduled to work in Dogwood cottage, who also covered medication technician duties for Elm and Fir cottages. On other days out of the week, there was a dedicated medication technician/caregiver scheduled for Dogwood cottage, and another medication technician who floated between Elm and Fir cottages. Title 22 of the California Code of Regulations does not provide specific staff-to-client ratios which must be maintained at all times. 22 CCR § 87411(a) states that “facility personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs.” 22 CCR § 87415(a)(2) states that “in facilities caring for sixteen to one hundred residents at least one employee shall be on duty on the premises, and awake,” and that “another employee shall be on call, and capable of responding within ten minutes.” There were 58 residents being cared for at this facility at the time LPA Moleski opened this complaint investigation on 11/21/24. During a tour of this facility on that date which included a survey of Aspen, Birch, Dogwood, Elm, and Fir cottages, LPA Moleski observed a minimum of two staff members present in each cottage, and did not observe any residents with any obvious signs of unmet needs, such as poor hygiene, or unmanaged pain, et cetera. Resident rooms inspected during this visit were clean and free of odor. LPA Moleski reviewed six residents’ files (R8-R13) for potential signs of neglect due to lack of care and/or supervision, such as an unusually large number of documented falls, evidence of open wounds, missed doses of medication, et cetera. LPA Moleski observed no concerning trends in any of these resident records. LPA Moleski interviewed seven residents (R1-R7). R1, R2, R4, R6, and R7 voiced no concerns with the current level of staffing in the facility. R2 described the facility as “really good,” and said caregivers respond to them quickly. R6 said that the facility has an abundance of staff who are kind and helpful. R3 said that the facility’s caregivers “need more help.” R3 said that staff take too long to respond to their calls for assistance, sometimes up to 30 minutes. R5 said the facility was “understaffed.” R5 said that they sometimes have to wait four or five hours to be repositioned in bed, and they sometimes wait up to 40 minutes for a response to their calls for assistance. [continued on 9099-C] LPA Moleski reviewed 30-day call button response logs for R3 and R5. While the average response time for each resident was roughly in line with the facility's expectation of 15 minutes per call at 14:13 and 15:11 respectively, there were a number of unusually high response times. For example, R3 had a recorded response time of more than 128 minutes on 2/23/25 and more than 80 minutes on 2/10/25. R5 had recorded response times of more than 77 minutes on 2/24/25, more than 57 minutes on 2/23/25, More than 65 minutes on 2/16/25, more than 80 minutes on 2/11/25, more than 181 minutes on 2/10/25, and a second call for more than 99 minutes on that same date. The facility’s health services director (S2) said that these entries showing excessive response times were likely errors. S2 said that the facility was in the process of changing call response systems due to these persistent errors. LPA Moleski noticed that a number of R5’s calls were recorded as coming from Birch Cottage, including the excessively lengthy calls from 2/24/25 and 2/10/25. However, R5 lives in Aspen cottage. R3's call log, meanwhile, included an entry from Dogwood cottage — the excessively long call recorded 2/23/25 — and a few calls had no location indicated. R3 also lives in Aspen cottage. To demonstrate the errors occurring in the electronic record-keeping system, S2 provided call button response logs from Fir and Elm cottages, which are not equipped with call buttons. These logs show a number of extremely long and extremely short response times recorded for the month of February 2023, ranging from a few seconds to several hours. LPA Moleski interviewed 15 staff members of this facility. Interviews with staff corroborated the staff schedules previously reviewed by LPA Moleski. The majority of caregivers, medication technicians, and management staff indicated that there are at least two caregivers stationed in every cottage serving residents, and when caregivers are busy providing two-person assistance to any particular resident, then a floating medication technician will cover the cottage floor to supervise residents. The majority of caregivers indicated that the medication technician will also cover them while taking breaks or while they are otherwise indisposed. S7 said that they have had to work alone in their cottage, but also said that they have always been able to meet the residents’ care needs. S8 said that there have been instances where there was just one caregiver in their cottage, and said that even two caregivers are not enough. However, S8 also said that all care tasks are completed, and residents do not have unmet needs. S9 said the current staffing levels were “challenging,” but also said that they are able to take care of all the residents. S9 said that the memory care director has asked staff to stay late to ensure sufficient coverage was maintained. All other staff members interviewed did not voice significant concerns regarding staffing levels at the facility. [continued on 9099-C] The department has determined the following as it relates to the allegation that the facility has insufficient staffing to meet resident needs: Based on interviews, observation, and record review, the above allegation is UNSUBSTANTIATED, which 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 deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Dial.the state’s words, verbatim · CDSS document, Mar 6, 2025 · control 27-AS-20241120092050

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct a case management visit. LPAs Moleski and Williams met with director James Dial and explained the purpose of the visit. LPA Moleski reviewed an incident report that was sent to the Community Care Licensing Division (CCLD) on 12/4/24. The incident report described a medication error which was discovered on 11/27/24 by a medication technician (S1). S1 had attempted to get a refill for a resident's (R1's) thyroid medication on that date, but was told that the medication was not able to be refilled, as there should be doses remaining, according to the incident report. The incident report stated that there was only one pill of the medication remaining at that time. In an interview, S1 said the medication, given in the correct dosage, should have lasted through 12/26/24. In an interview, the facility's health services director (S2) said that both night shift medication technicians (S3 and S4) had been giving one full pill of the medication, rather than the half pill prescribed. S2 said that they asked both S3 and S4 separately what they had been giving R1, and they both reported that they were giving one full pill. This had occurred on multiple occasions, according to the incident report. Neither S3 nor S4 were present at the facility during this visit. LPA Moleski reached out via telephone to each but did not receive a response during this visit. This facility is hereby cited per 22 CCR Section 87465(a)(4). An exit interview was held with Dial. Appeal rights and a copy of this report were left with Dial.the state’s words, verbatim · CDSS document, Dec 10, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Dec 11, 2024

"(4) The licensee shall assist residents with self-administered medications as needed." This requirement was not met as evidenced by: Based on interview and record review, a resident did not receive medications as prescribed, which poses an immediate threat to health, safety, or personal rights.the state’s words, verbatim · CDSS document, Dec 10, 2024

Plan of correction: Licensee agrees to conduct staff training regarding medication administration. vincent.moleski@dss.ca.gov

Allegation investigated: Resident fell due to lack of supervision

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Michelle Swearingen and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed two residents (R1-R2), seven staff members (S1-S7), and a resident’s responsible party (R1’s RP). LPA Moleski reviewed an incident report on 5/1/24 regarding the discovery of an injury on a resident (R1) on 3/30/24. The incident report stated that three staff members (S3-S5) who were working the night shift between 3/29/24 and 3/30/24 had observed a lump with bruising on R1’s back during a change of R1’s briefs. R1 was sent out to the hospital, according to the incident report. According to R1’s medical records, R1 was diagnosed with a spinal fracture at the hospital. [continued on 9099-C] Unsubstantiated LPA Moleski reviewed shift change notes regarding R1 dated between 3/26/24 and 3/29/24. A note made on the night of 3/29/24 stated that R1 refused to be changed for most of the night, but around 5 a.m., staff observed the bump and bruise on R1. The preceding notes do not make any indication of any observed injuries or falls suffered by R1. LPA Moleski reviewed R1’s file and did not observe any prior incident reports regarding falls suffered by R1 while at the facility. LPA Moleski reviewed R1’s preadmission appraisal, dated 11/20/23, which states that R1 did not need help in transferring in and out of bed. The appraisal was signed by R1’s RP. The appraisal states that R1 was active, but had difficulty climbing or descending stairs. Both R1’s appraisal and R1’s LIC 602, dated 11/20/23, indicated that R1 was fully ambulatory. In an interview, R2, R1’s spouse and a resident of this same facility, said that R1 fell three times while they were still living together, before they moved into the facility. In an interview, R1 said they could not recall what had happened on the night of 3/29/24 or the morning of 3/30/24. R1 was diagnosed with dementia, according to their LIC 602. In an interview, S4, said that R1 did not appear to be in pain on the night of 3/29/24 and the morning of 3/30/24. S4 said that R1 stayed up most of the night, calmly sitting in a chair in their room. S4 said that R1 had refused to be changed by the night shift staff until approximately 4:30 or 5 a.m. on 3/30/24, at which point R1’s injuries were discovered. In an interview, S5 said that from the start of their shift, R1 was in their room sitting in their chair. S5 said that R1 remained in their chair until both himself and S4 changed R1 in the early morning. S5 said R1 did not express pain at any point during the shift. S4 and S5 said that R1 is able to get up from the chair independently. S4 said R1 has fallen previously. LPA Moleski interviewed the two caregivers assigned to R1’s cottage during the afternoon shift on 3/29/24. In an interview, S6 said that R1 was in their chair during the afternoon shift, and did not want to get up, so S6 was not able to change R1, and therefore did not observe any injuries on R1. S6 said that R1 has fallen in the past, but is able to get up on their own. S6 said that, during crossover, the other caregiver on the afternoon shift, S7, said they had changed R1. [continued on 9099-C] In a phone interview, S7 said that they had changed R1 during the shift with their coworker, but had not observed any injuries on R1. LPA Moleski attempted to acquire additional information from S7, but the call was terminated. LPA Moleski called S7 again on 5/29/24, 5/31/24, and 6/14/24, and left voicemail messages each time. LPA Moleski also sent a text message asking to continue their conversation, to which he received no response. LPA Moleski was informed by Swearingen that S7 was terminated as of 8/12/24, in part due to attendance issues. LPA Moleski reviewed a disciplinary action notice regarding S7, dated 8/10/24. The notice stated that S7 was working a night shift on 8/5/24 and was present while a resident was out of bed and sitting on a bench in the common area of their cottage, but did not assist them back to their room. The department has determined the following as it relates to the allegation that a resident fell due to lack of supervision. Based on interviews, observation, and record review, the above allegation is UNSUBSTANTIATED, which 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 deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Swearingen.the state’s words, verbatim · CDSS document, Sep 12, 2024 · control 27-AS-20240404121416

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Michelle Swearingen and explained the purpose of the visit. LPAs Moleski and Williams reviewed 10 resident files (R1-R10) and 10 staff files (S1-S10). LPAs Moleski and Williams toured the facility with Swearingen and inspected common areas, the kitchen, bedrooms, bathrooms, and outdoor areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 71 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 108 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPAs Moleski and Williams observed fully-charged and up-to-date fire extinguishers, and carbon monoxide/smoke detectors. LPAs Moleski and Williams observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPAs Moleski and Williams observed locked carts for the storage of medication. LPAs Moleski and Williams observed locked closets for the storage of cleaning solutions. LPAs Moleski and Williams interviewed four staff members (S11-S12) and four residents (R11-R14). No deficiencies were cited during this visit. Technical assistance was provided relating to LIC 602s for dementia residents and staff training. An exit interview was conducted and a copy of this report was left with Swearingen.the state’s words, verbatim · CDSS document, Aug 26, 2024

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff did not provide sufficient notice of rate increase

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Michelle Swearingen and explained the purpose of the visit. This investigation consisted of interviews and record review. LPA Moleski interviewed a former resident’s responsible party (R1’s RP). R1’s RP said that they had not received any sort of written notification after a reassessment for R1 raised R1’s care costs. R1’s RP said they were only made aware of the increase in costs by looking through their bank statements. LPA Moleski reviewed a reassessment for R1 dated 12/11/23. The assessment was unsigned by either facility representatives or by R1’s RP. LPA Moleski asked Swearingen for any written notifications sent to R1’s RP regarding increased costs due to an increased level of care. Swearingen was unable to produce any such notifications. [continued on 9099-C] Substantiated A staff member (S4) claimed to have conducted a second reassessment on January 1, 2024 with R1’s RP present. LPA Moleski asked Swearingen for a copy of this second reassessment and written notifications sent regarding any increased care costs. Swearingen was unable to provide any such documentation in response to this request. Swearingen reached out multiple times requesting documentation from the prior management company in order to respond to LPA Moleski’s requests, but did not receive documentation to provide to LPA Moleski as described above. The department has determined the following as it relates to the allegation that staff did not provide sufficient notice of rate increase: Based on interviews and record review, sufficient written notice was not provided to R1’s RP after care costs were increased. Therefore, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per HSC Section 1569.657(a). An exit interview was held with Swearingen. A copy of this report and appeal rights were left with Swearingen. The refunds were processed effective 2/12/24. LPA Moleski reviewed a statement from February 2024 indicating that credits were provided for resident care and for room and board costs for the month of January. In an interview, R1’s RP said that they had received the refunds. LPA Moleski reviewed an incident report regarding R1’s hospital visit on 12/7/23. The report stated that R1’s RP called a staff member to check on R1. The staff member said that R1 was pocketing food and refusing meals. R1’s RP said R1 should be taken to the emergency room. R1’s RP picked up R1 around 1 p.m. and took R1 to the hospital. R1 was diagnosed with failure to thrive and was sent back on 12/12/23 with palliative care. In an interview, R1’s RP was aware of R1’s hospitalization and said they had visited R1 while hospitalized. In an interview, R1’s RP said that staff were “force feeding” R1. When asked for clarification, R1’s RP said that staff continued to ask R1 if R1 wanted to eat, although R1 did not want to eat. LPA Moleski reviewed R1’s daily notes and observed in the record a pattern of limited food intake and many refusals of food and drink. Refusals are documented in the notes, and the authors of the notes indicated on several occasions the exact amounts of food which R1 did accept. None of the staff members interviewed had witnessed staff members force feeding R1 or any other residents, although several did remark that R1 often refused meals and/or ate very little food. Among the staff members interviewed, one staff member (S5) said that on one occasion, S5 came in for their shift and observed that R1 had not been changed by the previous shift. None of the other staff members interviewed had witnessed neglect or lack of care for the resident. Three other staff members (S5, S7, S9) who worked directly with R1 said that R1’s continence needs were met and had not witnessed any instances were R1 had been waiting for care or needing to be changed. Of the staff members interviewed, two (S5, S9) said there were temporarily previous issues with phone calls being transferred from the main line to the appropriate cottage. None of the other staff members interviews reported any issues with the phone systems. LPA Moleski has not had issues reaching someone at the facility by phone. [continued on 9099-C] The department has determined the following as it relates to the allegations that staff force fed a resident, that staff did not inform a resident’s authorized person of a change in condition, that staff did not meet a resident’s needs, that staff did not refund fees according to the resident’s admission agreement, and that staff did not answer the facility telephone. Based on interviews and record review, the above allegations are UNSUBSTANTIATED, which 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 deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Swearingen.the state’s words, verbatim · CDSS document, May 30, 2024 · control 27-AS-20240227090631

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.657(a) · Plan of correction due date: Jun 13, 2024

“(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges.” This requirement was not met as evidenced by: Based on interview and record review, no notification was provided to R1’s RP after rates were raised due to an increase in level of care, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, May 30, 2024

Plan of correction: Licensee agrees to write a statement acknowledgement of the requirements and that they will be adhered to in the future. vincent.moleski@dss.ca.gov

Allegation investigated: Staff did not notify resident's responsible party of incident

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this allegation. LPA Moleski met with facility administrator Michelle Swearingen and explained the purpose of the visit. LPA Moleski opened a complaint investigation at this facility on 4/11/24. During the complaint investigation, it was revealed that a resident (R1) suffered a suspected unwitnessed fall on the morning of 3/30/24, and was sent to the hospital with an injury. During interviews, two staff members (S1-S2) said that R1's responsible party (RP) was notified by phone shortly after R1's injury was discovered. During an interview, R1's RP said they had been contacted by phone on the morning the injuries were discovered. [continued on 9099-C] Unsubstantiated The department has determined the following as it relates to the allegation that staff did not notify a resident's responsible party of incident: Based on interviews, the above allegation is UNSUBSTANTIATED, which 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 deficiencies were cited regarding this allegation. An exit interview was held and a copy of this report was left with Swearingen.the state’s words, verbatim · CDSS document, May 1, 2024 · control 27-AS-20240404121416

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Michelle Swearingen and explained the purpose of the visit. LPA Moleski opened a complaint investigation at this facility on 4/11/24. During the complaint investigation, it was revealed that a resident (R1) suffered a suspected unwitnessed fall on the morning of 3/30/24, and was sent to the hospital with an injury. LPA Moleski reviewed CCLD records and observed that no incident reports were received regarding this incident. LPA Moleski asked a staff member (S1) for a fax transmittal sheet from the incident report. S1 informed LPA Moleski that no transmittal sheet was available. S1 provided LPA Moleski with a printout of an incident report on 4/11/24, which described R1's injury and hospital visit. The incident report did not indicate that CCLD or any other agencies were notified of the incident. This facility is being cited per 22 CCR Section 87211(a)(1)(B). An exit interview was held with Swearingen. Appeal rights and a copy of this report were left with Swearingen.the state’s words, verbatim · CDSS document, May 1, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: May 13, 2024

"(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: ... (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision." This requirement was not met as evidenced by: Based on record review and interivews, LPA Moleski did not receive an incident report regarding a resident injury and hospital visit within seven days of the occurrence, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, May 1, 2024

Plan of correction: Licensee agrees to write a signed statement acknowledging the requirement to submit incident reports to CCLD in a timely manner. Licensee agrees to submit this statement to LPA Moleski by POC due date. vincent.moleski@dss.ca.gov

Allegation investigated: Staff did not administer resident's medication as prescribed. Facility does not have sufficient staff to meet residents' needs.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint. LPA Moleski met with facility administrator Michelle Swearingen and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed Swearingen, 17 staff members (S1-15, S17-S18), nine residents (R2-R10), and a former resident’s responsible party (R1’s RP). LPA Moleski reviewed R1’s medical records, medication prescriptions, and three months’ worth of medication administration records (MARs). LPA Moleski did not observe any indication of medication mismanagement in these records. [continued on 9099-C] Unsubstantiated In an interview, R1’s RP described an incident wherein a former staff member (S16) refused to provide PRN medication to R1. R1’s RP said that S15 witnessed the incident. In an interview, S15 said S15 had not witnessed any incident wherein S16 refused to provide medication to R1 without good cause, and had not witnessed any disagreement regarding medication between R1’s RP and S16. S15 said R1’s RP had often asked for R1’s medication during time periods in which the resident was not to receive additional doses, per R1’s prescriptions. Several other staff members (S1, S2, S5, S9, S13) reported experiencing similar incidents with R1’s RP. No other staff members interviewed were aware of an incident wherein S16 refused to provide medication to R1. LPA Moleski attempted to contact S16. Both phone numbers for S16 on file were inactive. Eleven caregivers and medication technicians (S5-S15) were interviewed regarding staffing levels at this facility. Among these 11, four staff members voiced concerns about the current staffing levels. S5 reported no problems meeting all residents’ needs. S6 said the cottage S6 works in is well staffed and reported no issues. S7 said S7 was able to meet all residents’ needs with the current staffing levels, although sometimes it takes a while to complete all tasks. S8 said S8 was able to meet all residents’ needs. S9 said staff were not overworked and were able to complete all tasks. S10 said sometimes medication technicians must pass medications in three cottages, and during those times they are short-staffed. S11 said S11 needs additional assistance from a medication technician when caring for a bedridden resident, but said all care needs were met. S12 said staffing was not sufficient during mealtimes, which are very busy. S12 said S12 was able to meet all residents’ care needs. S13 said the facility is short staffed during the lunch hour, but said all care needs were being met. S14 said current staffing levels were sufficient. S15 said staffing was sufficient provided that the right staff members were on shift. S15 said all care needs were being met. Among the nine residents interviewed, four voiced concerns regarding current staffing levels. R2 said all R2’s needs were met and felt staffing was sufficient. R3 said there were enough staff to meet R3’s needs. R5 was not sure if the facility was understaffed, but said R5’s needs were being met. R9 said that R9’s needs were being met and said there were enough staff. R10 said R10’s needs were being met and did not voice concerns regarding staffing or regarding care received at the facility. [continued on 9099-C] In an interview, R4 said that the facility was understaffed, and said staff had not offered to shower R4 for four days. LPA Moleski reviewed a shower schedule which showed R4 receives two showers a week. LPA Moleski interviewed three staff members, (S1, S17, and S18). S1 said R4 had been refusing care. S17 said R4 had been weak and unable to transfer. S18, who was present on R4’s scheduled shower day, said R4 was in pain and unable to transfer for the shower. During the same interview, R4 said that staff have made her wait for toileting assistance, but staff typically respond to R4’s call button, and are typically supportive of her needs. In interviews, R6-R8 said that the facility was understaffed due to lack of timely response to calls for assistance. LPA Moleski reviewed response times for a period of 30 days for R4, R6, R7, and R8. LPA Moleski observed average response times of 14 minutes and 41 seconds for R8 and 9 minutes and 32 seconds for R7. R4 and R6 did not press their pendants during the 30-day period reviewed. Previous records were not available. LPA Moleski reviewed staffing schedules and resident rosters. LPA Moleski observed that four of the five operational cottages are typically staffed with two caregivers each. The fifth is typically staffed by one or two caregivers. This fifth cottage was inhabited by seven residents at the onset of this investigation. The remaining four cottages were inhabited by 11 to 15 residents each. Medication technicians are typically assigned to cover two to three cottages each. Based on interviews, medication technicians assist with direct care of residents when needed. LPA Moleski visited this facility to investigate this complaint on 2/14/24, 3/11/24, 4/11/24, and 4/15/24. During these visits, residents observed appeared healthy and clean. LPA Moleski observed residents in common areas being supervised by staff members. The department has determined the following as it relates to the allegations that staff did not administer a resident's medication as prescribed, and that the facility does not have sufficient staff to meet residents' needs: Based on interviews, observation, and record review, the above allegations are UNSUBSTANTIATED, which 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 deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Swearingen.the state’s words, verbatim · CDSS document, Apr 15, 2024 · control 27-AS-20240208123439

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with resident care coordinator Daiya Jorlen and explained the purpose of the visit. LPA Moleski discussed reporting requirements with Jorlen and provided technical assistance on this topic. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Jorlen.the state’s words, verbatim · CDSS document, Oct 30, 2023

Allegation investigated: Staff do not provide resident medication as needed.

Licensing Program Analyst (LPA)s Jamie Ivey Canady arrived at the facility unannounced to deliver complaint investigation findings. LPA Ivey Canady explained the purpose of the visit and was met by Executive Director Morgan Greenwood. The investigation was conducted by LPA Ivey Canady. The investigation consisted of interviews with staff, reporting party, review of resident files, facility medical files, facility chart notes and caregiver daily notes. The Department has determined the following as it relates to the allegations: Staff do not provide resident medication as needed. Continued on LIC 9099 - C... Substantiated On 4/13/2023 LPA interviewed witness regarding current facility allegations. According to witness R1 was in the bed upon each visit to R1. However, according to witness statements, witness visited R1 in the late and early hours of the night. According document review, on page 5 of 6 on LIC602A dated 8/23/2022 R1 is listed as non-ambulatory. According to staff interviews, facility record files and resident interviews, residents are not left in bed for an extended period of time. Therefore in regard to the allegation Staff leave resident in bed for an extended period of time, the allegation is Unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. On 9/15/2023 LPA reviewed resident file documents for R1 received from facility on 4/18/2023. On 9/15/2023 LPA conducted staff and resident interviews regarding current allegations. On 10/10/2023 LPA conducted a tour of the facility and observed current residents to be clean. According to interviews with staff and residents there has been no residents that have been soiled for long periods of time. Based on interviews with staff, residents are checked every two hours to ensure they not soiled. On 9/15/2023 LPA received facility chart notes and files that have annotated times residents have been changed while soiled. Therefore in regard to the allegation Staff leave resident soiled for an extended period of time the allegation is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. On 9/15/2023 LPA reviewed resident files regarding services provided to R1. On page 3 of 6 of LIC602A letter E, Special Diet for R1 is filled and listed as "Puree Texture/CCHO Diet". On 9/15/2023 witness provided LPA with photographs of R1 meals and they are of puree texture. In accordance with R1s diet restrictions, facility did provide meal services to resident as prescribed. Therefore, the allegation Staff are not providing adequate meal services to resident is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Cont on 9099-C On 9/15/2023 LPA reviewed resident files regarding services provided to R1. Based on facility files and chart files R1 received showering and bathing services at the minimum of 2 to 3 times a week as was in alignment with facility and hospice care services. Based on staff and resident interviews, residents received showering services based on facility agreements and services were logged in facility chart records. On 9/15/2023 LPA interviewed facility residents and staff regarding current allegations. Based on interviews and record review, R1 has been receiving showering by facility staff and hospice staff. Therefore the allegations Staff are not meeting resident’s showering needs is unsubstantiated. . An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED Exit interview held with Executive Director Morgan Greenwood and copy of report was provided. On 4/13/2023 LPA interviewed witness regarding current facility allegations. According to witness, R1 was not receiving pain medications as prescribed. On 9/15/2023 LPA conducted a review of facility medication logs and chart notes for the period of 9/23/2022 to 12/18/2022. Based on facility record review, facility did not provide medication to R1 as prescribed. Based on LPA observation, facility did not supply all requested documents as requested by LPA on 9/15/2023. On 9/18/2023 LPA received additional medication chart notes and documents and it was learned facility had not properly annotated medication resident had received. Therefore, staff did not annotate resident medication in accordance with Title 22 Regulations. Based on medication file review and review of the undated Sign-Out Medication Release Form received from the facility, records show missing pain medication that R1 did not receive upon out processing. Therefore in regard to the allegation Staff do not provide resident medication as needed, the allegation is Substantiated. Based on LPAs medication file review and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview with Administrator. Appeal rights and report given.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 27-AS-20221227132746

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87506(d)(H) · Plan of correction due date: Oct 10, 2023

87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours...(H) Records of current medications as specified in Section 87506(b)(12)...This was not met as evidenced by: On 9/15/2023 the Department representative LPA visited the facility to investigate complaint allegations. While at the facility LPA requested resident medical documents and files. The Licensee did not ensure staff could provide documents requested by the Department as required by Title 22 Regulations. This poses an immediate Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2023

Plan of correction: Licensee states they will ensure the documents from previous years are readily available by providing LPA a photo of where the documents are kepty No Later Than (NLT) 10/11/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(4) · Plan of correction due date: Oct 10, 2023

87464 Basic Services (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications...This was not met as evidenced by: Based on facility medical record review and witness statements, Licensee did not ensure R1 recieved medication as prescribed. This poses an immediate Health and Safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 10, 2023

Plan of correction: Licensee states on October 3, 2023 there has been a full med tech retraining regarding ordering medication, transcribing medication as well as proper use of physicain phone calls and reminders. Trainnig provided by disctrict nurse for Pegasis Inc. Training documentation will be provided to LPA NLT 10/11/2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit in order to follow up on an incident report. LPA Moleski met with facility administrator Morgan Whinery and explained the purpose of the visit. LPA Moleski reviewed an incident report that described an unwitnessed fall suffered by a resident (R1) on September 13. Whinery said R1 went to the hospital after the fall and returned on hospice. R1 died on September 29, 2023, according to Whinery. The staff member on duty was not present during this visit. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Whinery.the state’s words, verbatim · CDSS document, Oct 3, 2023