Ivy Park at Oakland Hills

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Staff do not adequately supervise resident(s) in care. Licensee does not ensure that staff are adequately trained.

On 05/05/2026 at 10:10 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to continue the investigation and to deliver findings in regard to the allegations above. LPA met Yolanda Harrell, Executive Director and explained the purpose of the visit. During the course of the investigation, the LPA conducted interviews with four staff (S1, S2, S3,S4), W1 and reviewed R1's hospice records, as well as resident records for R1, R2, and R3, including admission agreements, physician reports, and care plans. The LPA also reviewed three staff records (S2, S3, S4), including training logs. The LPA toured three resident rooms (R1, R2, R3), and the staff roster, resident roster, and staff schedules for the months of January and February were obtained as part of the investigation. ALLEGATION: Staff do not adequately supervise resident(s) in care - Unsubstantiated ***CONTINUE ON 9099C*** Unsubstantiated ***CONTINUE FROM 9099*** The LPA interviewed staff (S1, S2, S3), additional staff (S4) on a follow-up visit, as well as W1. Staff consistently stated that residents who are at risk for falls are monitored closely and checked on regularly. One staff member shared that “residents who need more supervision are checked frequently throughout the shift.” The LPA reviewed resident records, including care plans and physician reports, which showed that R1’s needs, including fall risk and mobility limitations, were assessed and documented. The LPA reviewed hospice files and R1's charting notes, which revealed that hospice communicates resident needs to staff and check-in observations were documented daily. During the tour, the LPA observed a check-in log in R1’s room showing that staff were checking on the resident at regular intervals and documenting those check ins with initials. ALLEGATION: Licensee does not ensure that staff are adequately trained - Unsubstantiated During the course of the investigation, the LPA reviewed staff training records and conducted interviews with staff. The LPA reviewed staff files, including S2 and S3, and an additional file (S4) during a follow-up visit. All training records were up to date and showed that staff completed required initial and ongoing training, including annual training hours. The training included topics related to resident care, such as dementia care and supervision. Staff interviewed were able to explain their responsibilities and how they provide care and supervision. One staff member stated that “we receive regular training, especially for residents with higher care needs.” Additionally, a review of R1’s hospice records revealed that a hospice agency was overseeing R1’s medical needs, including oxygen use, and coordinating care with facility staff. The LPA reviewed hospice communication logs between hospice and care staff. This agency has investigated the allegations above We have found that the allegations were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, May 5, 2026 · control 15-AS-20260126155656

Allegation investigated: Staff restrict residents from having visitors at the facility Staff do not ensure residents are spoken to in an appropriate manner

On 02/27/2026 at 10:30 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to deliver findings in regard to the allegations above. LPA met Yolanda Harrell, Executive Director and explained the purpose of the visit. Allegation: Staff restrict residents from having visitors at the facility - Unsubstantiated During the investigation, LPA interviewed five staff members (S1–S5), two residents (R1 and R2), W1, and reviewed R1 and R2’s facility files including the Power of Attorney (POA) documents. Staff consistently stated that the facility does not restrict visitors unless there is a specific safety concern or requirement. ***CONTINUE ON 9099C*** Unsubstantiated ***CONTINUE FROM 9099*** S1 stated, “Per the Parole Officer’s guidance, W1 was unable to meet on site; however, we arranged an outside space for the meet up.” S1 further stated that “the priority is the health and safety of all residents.” S2 stated, “We follow any legal or supervision requirements given to us. We don’t stop visits without a reason.” S1 further added, “If there are restrictions from a parole officer or court order, we must follow them, but we still try to accommodate visits in a safe way.” Review of records did not show documentation that the facility issued a blanket restriction on visits. Staff interviews revealed that facility followed instructions provided by the Parole Officer while attempting to accommodate visitation in an alternate manner. 2- Allegation : Staff do not ensure residents are spoken to in an appropriate manner - Unsubstantiated During the investigation, LPA interviewed five staff (S1-S5) members and four residents (R1- R4) regarding communication between staff and residents. Residents R1 and R2 both denied being spoken to in a threatening or inappropriate manner. R1 stated, “They talk to us normal. No one threatens me.” R2 stated, “Staff are respectful. If they remind us about rules, they explain why.” Staff interviews consistently indicated that they are trained to communicate respectfully and calmly. LPA reviewed five staff training records..” .No staff admitted to threatening statements, and residents interviews did not reveal that staff spoke to residents in an appropriate manner. ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099C*** This agency has investigated the allegations above. We have found that the allegations were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 27, 2026 · control 15-AS-20251020095016

Allegation investigated: Physical Abuse/Corporal Punishment while in care

On 02/20/2026 at 12:05 PM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to deliver findings in regard to the allegation above. LPA met Yolanda Harrell, Executive Director and explained the purpose of the visit. During the course of the investigation, LPA interviewed four staff (S1–S4) and obtained and reviewed records related to R1 and R2’s care, including admission agreements, physician reports, and care plans. Records reviewed did not contain incident reports, notes, or documentation indicating physical abuse, injury, or concerns involving corporal punishment while residents were in care. LPA also obtained contact information for the responsible party/POA to conduct additional follow-up. ***CONTINUE ON 9099C*** Unsubstantiated ***CONTINUE FROM 9099*** during the interview with LPA, S1 stated that "the incident occurred before R1 and R2 were admitted and residing at the facility. LPA reviewed R1 and R2's files as well as the admission agreements. 8/16/2025 was the admission date for R1 and R2. S1 further stated "R1 and R2 were admitted to the community on 08/16/2026. The first week that R1 was in the community, she received a visit from a home health nurse. When the home health nurse was conducting her evaluation, R1's sister mentioned to the nurse that there was an incident that happened before they were admitted to the community alleging that R2 hit her".The home health nurse reported this information to the ombudsmen and CCL. Additional interviews with S2,S3 and S3 did not reveal any reports of physical abuse involving R1 and R2. S1 stated that residents’ personal rights are respected and not interfered with by the facility, and that staff prioritize residents’ health and safety at all times. This agency has investigated the allegations above. We have found that the allegations were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 20, 2026 · control 15-AS-20251006162442

Allegation investigated: Staff does not ensure resident's pressure injuries are being properly treated. Staff did not seek medical attention to resident. Staff does not ensure resident's electronics are in good repair.

On 11/12/2025 at 12:20 PM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to deliver findings in regard to the allegations above. LPA met Yolanda Harrell, Executive Director and explained the purpose of the visit. Over the course of the investigation, LPA conducted interviews with five staff members (S1–S5) and two residents (R2–R3), obtained staff and resident rosters, and reviewed fresident records including but not limited to R1’s admission agreement, hospice file, and needs and services plan. LPA also reviewed staff training files, hospice notes, and physician reports. A tour of R1’s former room was conducted, and additional follow-up phone interviews were completed with S4 and S5. It was confirmed that R1 no longer resides in the facility. Allegation: Staff does not ensure resident’s pressure injuries are being properly treated - Unsubstantiated ***CONTINUE ON 9099C*** Unsubstantiated ***CONTINUE FROM 9099*** W1 stated, “R1 had wounds that weren’t healing, and I don’t think staff were changing her dressings the way they should.” W1 reported that R1’s family had expressed concern that her pressure injuries appeared worse over time. During interviews, staff (S1–S4) consistently reported that R1 was admitted to the facility under hospice care with existing pressure injuries. S1 stated, “When she moved in, she already had open wounds, and hospice was coming in daily to do the wound care.” S2 also stated, “We assisted hospice nurses when they came; we didn’t do the wound care ourselves unless instructed.” Review of hospice documentation and care notes showed consistent visits by hospice nursing staff with records of wound care performed per physician orders. During interviews, R2 and R3, both current residents, reported no concerns with staff. Allegation: Staff did not seek medical attention for the resident - Unsubstantiated W1 stated, “When R1 wasn’t eating for a few days, her family wanted her taken to the hospital, but the staff told them no.” According to W1, family members were concerned about R1’s condition and weight loss. Interviews with staff indicated that hospice was overseeing R1’s care plan and directing all medical decisions at the time. S1 stated, “we coordinated closely with hospice daily and updated the responsible party.” S3 added, “The nurse visited regularly and adjusted her plan; the family was aware hospice was managing her care.” LPA reviewed hospice communication notes and progress reports showing regular hospice visits, physician coordination, and documentation of family communication regarding R1’s condition. The records confirmed hospice was aware of the resident’s decreased appetite and continued to provide end-of-life comfort care. Resident interviews (R2–R3) revealed no concerns about staff not providing medical attention when needed. ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099C*** Allegation: Staff does not ensure resident’s electronics are in good repair - Unsubstantiated W1 stated, “R1's TV never worked since she moved in, and every time we asked staff to fix it, they just said they would but nothing ever happened.” W1 reported that the TV belonged to the facility and that R1 spent most of her time in her room without entertainment. During interviews, staff did not confirm that the TV in R1's room was not working. S1 further stated that "the admission agreement specifies the facility does not provide TVs and that R1 brought her own TV. However, if a resident's personal electronics, such as a TV, do not work, staff sometimes assist with repairs as a courtesy". LPA reviewed the admission agreement, which revealed that the facility is not responsible for resident owned electronics or similar amenities. LPA also toured R2 and R3's rooms and facility's common entertainment area. R2 also stated " if I need something, or my TV remote runs out of battery, I have seen staff come and help. Resident's electronics were observed to be in operating condition. This agency has investigated the allegations above. We have found that the allegations were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 12, 2025 · control 15-AS-20250730081507

Type of visit: Case Management - Other

On 10/03/2025 at 12:45 PM, Licensing Program Analysts (LPAs) Ardalan Gharachorloo and Greg Clark arrived unannounced to deliver amended report for complaint # 15-AS-20250514141716. LPA met with Administrator, Yolanda Harrell, Executive Director, and explained the purpose of the visit. Amended report delivered to Executive Director. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 3, 2025

Type of visit: Required - 1 Year

On 09/29/2025 at 9:20 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director,Yolanda Harrell and explained the purpose of the visit. LPA toured the facility including but not limited to 6 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 71 degrees F. The average hot water temperature in 5 residents bathrooms were measured at 106 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 05/13/2025. Emergency Disaster Plan was last reviewed and posted on 12/31/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 08/20/2025. LPA reviewed 5 residents records and 5 staff records, and all were complete. LPA also reviewed a sample of resident’s medications. The following documents were reviewed during the visit: Personnel Report, Emergency Disaster Plan, and Current Administrator’s Certificate. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 29, 2025

Allegation investigated: Staff do not ensure that resident's incontinence needs are met Staff are not following a resident's meal plan Staff do not provide resident with housekeeping services Staff do not administer resident's medications as prescribed Staff do not ensure that the facility maintains a phone that is in working order Staff do not assist a resident with receiving mail Staff has not provided a resident's responsible party with a copy of facility fees Staff did not safeguard a resident's confidential information Staff do not provide resident with laundry service Staff do not observe resident for change in conditions

On 09/10/2025 at 11:20 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to deliver findings regarding above allegations.LPA met with Executive Director, Yolanda Harrell and explained the purpose of the visit. During the course of the investigation LPA conducted an interviews with 8 staff (S1-S8), 3 residents (R1,R2,R3), and collected the following documents: Resident and staff roster, staff schedule, House keeping and laundry schedule,sample of care fees increase letter, R1's Ledger, special diet schedule and hospice files. LPA also reviewed R1,R2, and R3 files, and toured R1's room. Staff do not ensure that resident's incontinence needs are met: Unsubstantiated Licensing Program Analyst (LPA) conducted a tour of Resident 1's (R1) room, interviewed S1 and S2, and reviewed R1’s care plan along with the staff schedule. During the tour, R1 was found in his room in a clean and sanitary condition, with no indications of unmet incontinence needs. ***CONTINUE ON 9099C*** Unsubstantiated ***CONTINUE FROM 9099*** Interviews with S1, S2 and indicated that R1 receives regular assistance with incontinence care in accordance with their care plan. A review of the staff schedule revealed that sufficient staff were assigned to provide necessary care. LPA reviewed the care plan. The care plan detailed the frequency of incontinence checks and the type of support R1 should receive. A review of the incontinence care logs showed that staff documented each check and change. LPA also checked the log for how checks are being documented. These logs were complete, consistent, and matched the interventions written in the care plan. The staff schedule also confirmed that there are enough staff assigned to meet R1’s needs. Allegation: Staff are not following a resident's meal plan: Unsubstantiated LPA interviewed S1, S4, the head chef, and two kitchen staff (S6,S7). S1 stated that R1’s meal plan remains unchanged and continues to follow the guidelines set by hospice services, as outlined in the last care plan dated 08/2024. S1 also stated that she regularly checks in with kitchen staff to ensure R1s special diet needs are met. LPA also interviewed S4 who stated that “the special meal plan is posted for reference in the kitchen. LPA toured the kitchen and observed the meal plan posted in the kitchen. LPA also requested a sample of the food being served to R1 and interviewed R1 regarding his meals. R1 stated that “the food is fine”. LPA also interviewed R2 and R3 who stated they have no complaints about the food. Allegation: Staff do not provide resident with housekeeping services: Unsubstantiated LPA interviewed S1 who stated that “R1 has a designated housekeeping day and that “staff continuously provide housekeeping services as scheduled”. S1 provided documentation, including the housekeeping schedule and staff assignments, which confirmed that regular cleaning services are in place for R1. LPA also reviewed the housekeeping schedule, which reflected consistent and ongoing housekeeping services being provided. Additionally, LPA conducted a tour of R1’s room and observed that the room was clean and sanitary. LPA interviewed R2 and R3 who stated they have no issues with housekeeping. LPA also toured R2 and R3's room and were clean. ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099C*** Allegation: Staff do not administer resident's medications as prescribed: Unsubstantiated LPA reviewed R1’s physician reports and Medication Administration Records (MARs). LPA also interviewed S3 and S5, both of whom confirmed that they follow the MAR orders when administering medications to R1. A review of a sample of R1’s medications further indicated that they are being dispensed in accordance with the prescribed orders. Additionally, LPA interviewed S1 who stated that “staff strictly adhere to the MAR orders”. S1 also stated that she “advised W1 to contact her directly any time with any concerns to clarify any misunderstandings”. LPA spoke with S1 and reviewed Resident 1’s (R1) Medication List for June and July 2024. The records showed that all medications were given as prescribed. S1 explained that the eye drops are marked “as needed,” and the nurse decides if R1 should get them after checking R1 condition. Allegation: Staff do not ensure that the facility maintains a phone that is in working order: Unsubstantiated LPA checked the facility phone line and conducted a sample phone call, confirming that the phone was in working order. LPA also interviewed S1 who stated that the facility maintains a phone line accessible to all residents 24/7 and that it remains in always working condition. Additionally, LPA interviewed the concierge (S7), who confirmed that residents use the phone daily. S7 also stated that staff regularly transfer calls and deliver messages to residents as needed. LPA also interviewed R2 and R3 who stated that they have no issues with the phone line. Allegation: Staff do not assist a resident with receiving mail: Unsubstantiated LPA interviewed the concierge (S7), who stated that mail is delivered to residents daily. LPA also reviewed a sample of mail. LPA observed that some mails have been delivered to resident’s room. LPA interviewed S1, who confirmed that front desk staff are responsible for ensuring that mail is delivered directly to residents’ rooms. S7 provided examples of mail that had been recently delivered to residents. LPA observed 2 envelopes on the table next to R1. LPA interviewed R2 who stated that "I see mails at my front door daily". R3 also stated that she has no concerns with the mails. ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099C*** Allegation: Staff has not provided a resident's responsible party with a copy of facility fees - Unsubstantiated LPA interviewed S1, who stated that a letter notifying the resident’s responsible party of the facility fee increase was sent out 90 days in advance. S1 stated that W1 received a copy of this letter, which outlined the updated care fees. Additionally, S1 clarified that all facility fees were increased at the same time for all residents. LPA reviewed the admission agreement, a copy of the dated notification letter disclosing the increase, as well as the facility ledger and correspondence documents, which showed that the required notice was provided. Allegation: Staff did not safeguard a resident's confidential information - Unsubstantiated LPA toured the medication room and the designated storage area for resident and staff files. LPA observed that all doors to these sensitive areas were restricted and locked. Additionally, LPA interviewed S2 and S3, both of whom stated that medication records are secured with password protection and can only be accessed by authorized staff. LPA also interviewed S1 who stated that all areas containing confidential resident information are secured and only accessible to authorized personnel. Allegation: Staff do not provide resident with laundry service: Unsubstantiated LPA interviewed S1, who stated that the facility follows a designated laundry schedule for all residents. S1 stated that S1 meets regularly with shift managers and staff to ensure that scheduled laundry services are provided. S2 stated that the shift reports are conducted daily to maintain accountability for resident care tasks, including laundry services. S1 provided LPA with a copy of the facility’s laundry schedule, which outlines the assigned service times. LPA also interviewed S8 who stated that laundry services are completed based on the schedule provided by resident’s care coordinator. LPA toured the laundry room and interviewed R2 and R3 who stated no concerns with the laundry service. ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099C*** Staff do not observe resident for change in conditions: Unsubstantiated LPA reviewed the R1’s physician report, medication records, needs and services plan and hospice care plan. S1 also provided the staff communication sheet related to the logging of changes in condition to the LPA. LPA interviewed S1 who stated that the facility’s nurse is scheduled to check in with residents daily to assess any changes in condition. S1 stated that any observed changes are documented accordingly. LPA reviewed the log during the interview as well as the updated communication log with hospice. LPA observed that observation notes are dated, and care staff, med tech and wellness nurse log observations for residents. This agency has investigated the complaint allegations above. We have found that the allegations were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 10, 2025 · control 15-AS-20250113082533

Allegation investigated: The facility did not notify the responsible party in a timely manner. Staff does not meet training requirement.

On 09/05/2025 at 9:55 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to continue the investigation and deliver findings regarding above allegations.LPA met with Executive Director, Yolanda Harrell who arrived at the facility at 11:05 AM, and explained the purpose of the visit. During the course of the investigation,LPA conducted interviews with 4 staff (S1-S4) and 3 residents (R1-R3), obtained the staff and resident roster, and gathered documents related to R1's care as well as hospice file, internal incident reports, communication logs and charting notes. LPA also reviewed 3 staff files and toured R1's room. Allegation: The facility did not notify the responsible party in a timely manner - Unsubstantiated W1 reported, “I should have been notified immediately. There was no communication for at least an hour after the fall.” LPA interviewed S1 who stated, “When an emergency occurs, caregivers notify the med tech and unit lead, and they assess the situation almost immediately. ***CONTINUE ON 9099C*** Unsubstantiated ***CONTINUE FROM 9099*** An internal incident report is completed, and the responsible party is contacted.” S2 stated, “In this situation, we assessed and called hospice, and notification to the person in charge happened right away.” S3 provided the incident report and change of condition log, which reflected that staff documented the fall, assessment, and communication with hospice. S4 also confirmed that she notified the med tech immediately after discovering the situation. LPA’s review of the communication logs and call logs confirmed that notifications were made to hospice and to responsible parties after the incident. Documentation reviewed included the internal incident report with instructions and protocols for care following the fall. Interviews with staff were consistent in describing the procedure: caregivers alert the med tech and unit lead, complete incident documentation, and notify hospice and the responsible party. Allegation: Staff does not meet training requirements - Unsubstantiated LPA reviewed three staff files (S1–S3), including annual training logs, and continuing education records. LPA also reviewed R1's file. R1 is on hospice. W1 reported, “An untrained med tech who is not a nurse assessed whether or not my mother was okay.” Interviews with staff confirmed that the caregiver on duty notified the med tech, who then notified the nurse and hospice. S4 stated, “I notified the med tech right away to escalate it after finding out the situation in Room 119.” ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099C*** Staff files reviewed by LPA contained documentation of orientation, and annual continuing education hours were reviewed.Training logs showed that caregivers and med tech had completed the mandated annual training. S3 provided LPA with the internal incident report and care plan for R1, which confirmed that documentation and reporting protocols were followed. Staff interviews with S1–S4 revealed facility’s process for immediate reporting to the med tech, escalation to the nurse, and notification of hospice and responsible parties. This agency has investigated the complaint regarding allegation above. We have found that the allegations were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. .Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 5, 2025 · control 15-AS-20250610101445

Allegation investigated: Staff restrained a resident in care resulting in injuries. Staff did not notify resident's responsible party of an incident. Staff did not seek medical attention for a resident in care.

This is an amended report.On 08/12/2025 at 10:50 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to investigate and deliver findings regarding above allegations.LPA met with Executive Director, Yolanda Harrell and explained the purpose of the visit. Over the course of the investigation,LPA conducted interviews with five staff (S1-S5) and gathered documents related to R1's care as well as incident reports, Needs and services plan, Physicians report, MARs, communication logs and charting notes and discharge summary. LPA toured the memory care unit and R1's room. LPA also reviewed R2 and R3's files. Allegation: Staff restrained a resident in care resulting in injuries - Unsubstantiated W1 stated that on 04/30/2025, after dinner, R1 became upset when she was told to stop helping with dishes and swung at a staff member. ***CONTINUE ON 9099C*** Unsubstantiated ***CONTINUE FROM 9099*** W1 stated that R1 was held back by her wrists, resulting in injuries to her wrists, chest, and left arm, as well as a lump on her forehead. W1 stated that R1 hit her head on a wall due to being placed in a restraint. During interviews with the LPA, S1 stated that staff intervened to prevent R1 from falling or injuring herself but did not restrain her. S3 added that R1 was agitated and staff stood close to redirect her and block contact, but no forceful restraint was used. S4 stated, “I saw staff guide her away from the table; no one held her down.” S5 stated by phone, “I touched her elbow to guide her; she pulled away quickly and may have bumped herself.” LPA reviewed the incident report, charting notes, and daily care logs for 04/30/2025. The documentation reflected that R1 became upset, attempted to strike another resident, and was verbally redirected. There was no documentation of physical restraint. During the facility tour, LPA observed R1 in the common area and did not observe any signs of distress. Allegation: Staff did not notify resident's responsible party of an incident - Unsubstantiated W1 stated she was not informed of the 04/30/2025 incident or the 05/01/2025 incident and only learned about them afterward. W1 stated that she would have wanted immediate notification of any injury. In the interview with LPA, S2 stated that after the 04/30/2025 incident, she called W1 several times but received no answer and left a message for the next shift to continue follow-up. S4 stated that he heard S2 say on the phone, “No answer — I’ll try again after rounds.” S1 stated that follow-up calls were part of the facility’s procedure and that a care conference was scheduled after the incidents to discuss R1’s care needs. LPA reviewed the facility communication logs, incident reports, and staff notes and updates for shift changes. The logs documented call attempts to W1’s listed number on both dates, with “no answer” recorded. Review of the incident report submitted to CCL dated 05/15/25 revealed that W1 was notified of the incident. ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099C*** Allegation: Staff did not seek medical attention for a resident in care - Unsubstantiated W1 stated that after the 05/01/2025 incident, in which R1 became angry, fell, and hit her face on a wheelchair, and that the facility did not arrange for medical evaluation, so W1 took R1 to urgent care the next day. S1 stated that staff assessed R1 immediately following the incident and found a small red mark on her cheek but no swelling, bleeding, or signs of distress. S5 also added, “She was alert, eating dinner, and talking to staff. We kept an eye on her all evening.” S3 further stated that R1 was monitored for 24 hours following the incident and her vitals remained stable. LPA reviewed R1's discharge summary from Stanford Medicine dated 5/5/25 which revealed that R1's X-rays all came back negative. LPA reviewed the internal incident report, progress notes, and the facility’s fall protocol. Documentation showed that staff assessed R1 after the occurrence of the incident, recorded their observations, and monitored her condition per facility policy. This agency has investigated the allegations above. We have found that the allegations were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 12, 2025 · control 15-AS-20250514141716

Allegation investigated: Facility staff did not ensure resident was broguht down for meal service.

On 06/19/2025 at 1:45 PM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegation above. LPA met Yolanda Harrell, Administrator, and explained the purpose of the visit. During the course of the investigation, LPAs interviewed S1, and W1. LPA reviewed R1’s needs and services plan and W1's email correspondence with the facility. Allegation: Facility staff did not ensure resident was brought down for meal service : Unsubstantiated LPA interviewed S1 regarding the complaint received from W1 on 06/17/2025. W1 had initially reported that R1 was not brought to the dining room for breakfast and was found in bed without pants when the private caregiver arrived around 11:00 AM. ***CONTINUE ON 9099C*** Unsubstantiated ***CONTINUE FROM 9099*** W1 also mentioned that staff had confirmed R1 missed breakfast. This concern was originally sent via email to facility staff, and W1 expressed frustration over lack of timely communication regarding care issues. However, later the same day, W1 sent a follow up email stating that after receiving clarification from staff, she realized she had misread the caregiver’s text and acknowledged that S2 in fact provided care. W1 sent an email to S1 on 06/17/2025 stating “ I will withdraw my complaint to the DSS regarding today” and stated " she had no reason to doubt the staff member involved". This agency has investigated the complaint alleging Facility staff did not ensure resident was brought down for meal service. We have found that the complaint was 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. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 19, 2025 · control 15-AS-20250617132913

Allegation investigated: Licensee did not provide resident with a refund

On 04/11/2025 at 1:30 PM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to deliver findings regarding above allegation.LPA met with Executive Director, Yolanda Harrell and explained the purpose of the visit. Allegation: Licensee did not provide resident with a refund - Unsubstantiated During the investigation, LPA interviewed the Executive director and Business office director. LPA also obtained the following documents: a copy the R1's admission agreement, R1's payment Ledger/Invoices, and a copy of the 30 day notice. On 03/24/2025, LPA received a ledger from the Executive Director showing that the account has been settled and the late fee has been removed. Executive confirmed that the facility has given R1 the 60% community fee along with removing the late fee. ***CONTINUE ON 9099 C*** Unsubstantiated *** CONTINUE FROM 9099*** This agency has investigated the complaint regarding allegation above. We have found that the complaint was unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. .Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 11, 2025 · control 15-AS-20250313120104

Type of visit: Case Management - Other

On this day at around 2:30 pm, LPAs Luisa Fontanilla and Ardalan Gharachorloo conducted Component lll with Executive Director (ED) Yolanda Harrell. Caseload LPA Gharachorloo presented Component lll power point presentation with ED. A copy of this report was provided to ED.the state’s words, verbatim · CDSS document, Aug 16, 2024

Type of visit: Prelicensing

On this day at around 10 am, Licensing Program Analysts (LPAs) Luisa Fontanilla and Ardalan Gharachorloo arrived at the facility unannounced to conduct pre licensing inspection and met with Executive Director (ED) Yolanda Harrell. LPAs explained to Harrell the purpose of the visit. This pre licensing is being conducted due to a change in ownership (CHOW) of the facility. The facility has an approved fire clearance for 96 non ambulatory and 4 bedridden residents. LPAs inspected the facility inside and out including but not limited to the assisted living and Memory Care units, common areas, kitchen, dining and activity room. Hot water temperature was measured in five resident rooms at 106 Fahrenheit. There was sufficient supply of perishable and non perishable foods. Multiple fire extinguishers that appeared full and were last serviced on 12/7/2023 were observed. The facility's fire clearance was approved on 1/22/2024. Last fire drill was conducted on 7/18/2024. During the resident file review, LPAs observed Resident 2 (R2) Physician's Report does not have the physician's signature. R2 is diagnosed with Dementia. R3's Physician's Report does not have TB test. R3 is diagnosed with Dementia. The ED will have R2 and R3 Physician's Reports completed and send a copy to CCL by The facility is not yet licensed. LPAs will notify CAB about the visit.the state’s words, verbatim · CDSS document, Aug 16, 2024