Ivy Park at Rockville

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a Case Management visit related to a self-reported Special Incident Report (SIR) received from Ivy Park at Rockville on 07/18/2026. LPA met with Assistant Living Director Denisha Lewis. At approximately 1:30 PM Administrator Tedra Godfrey arrived to further assist with today's Case Management visit. LPA obtains documents and made observations Report was reviewed with Tedra Godfrey whose signature denotes receipt.the state’s words, verbatim · CDSS document, Jul 21, 2026

Allegation investigated: Staff are not adequately trained Staff mismanage resident medication

At approximately 11:55 AM, Licensing Program Analyst (LPA) Stevenson arrived unannounced to deliver findings for this complaint Investigation regarding the above allegations and met with Administrator Tetra Godfrey. On 03/25/2026 Community Care Licensing (CCL) received a complaint alleging that staff at Ivy Park “are not adequately trained” Complainant reports that, “staff appear inadequately trained, frequently fail to follow protocols” especially around the placement and use of a specialty device prescribed for R1. LPA conducted witness, staff and resident interviews, obtained documents and evidence and made observations. Continued on LIC9099-C Substantiated Continued from LIC9099 On 04/24/2026 LPA obtained a copy of a video of a specialty device system discarded in a garbage can and improperly set up per witness (1) W1. An interview with W1 indicates the speciality device was improperly set-up and discarded when staff could not facilitate proper use of the device. In addition, LPA obtain a photo on 05/21/2026 of the Resident end of the same device in a trash can and on 05/22/2026 LPA obtained a second photo of the collection side of the same device improperly set up. In an interview with staff member S3, S3 indicated that some of the staff applying the speciality device to R1 were “not trained” in use of R1’s specialty device, and that a private caregiver of R1 had written down the exact details of how to apply the device. An interview with staff member S1 indicates they had personally learned how to apply R1’s medical device from a hospice nurse not employed by Ivy Park, (rather than through an inservice provided at Ivy Park at Rockville) A similar interview with staff member S2, had S2 saying that the use of R1’s medical device was a particularly private and invasive procedure and as such would not have be acted out or demonstrated with new staff in front of R1. When S2 was asked, “Does your team (at Ivy Park) have written step-by-step instructions on how to apply the specialty device to R1 or how to help R1 use their CPAP and if the trainings were documented", S2 offered, “It is not something we typically see a lot of, again it would be shadow training or R1’s private caregiver explaining how it is done. The training is not documented” Because photos and a video obtained by this LPA demonstrate the improper set-up of R1’s medical device and because no evidence of staff documented training in the application or use of the speciality device could be obtained at the time of the investigation, the preponderance of evidence standard has been met, therefore the above allegation of “staff are not adequately trained” is found to be SUBSTANTIATED. A type B citation for violation of CCR 87468.2(a)(4) which requires caregivers to be competent in the care they provide is being sited. See 9099-D page. In addition, on 03/25/2026 CCL received a complaint alleging that staff at Ivy Park at Rockville failed to ensure PRN and prescribed medicines were dosed and administered properly. An interview with R1 revealed that they had long received the incorrect dose of their prescribed medicine and once the dosage was corrected, a long term health concern of theirs improved. Continued on LIC9099-C Continued from LIC9099-C A subsequent interview with W1, indicates W1 raised the medicine administrator error to the Management at Ivy Park with W1 indicating that it was not until W1 raised the administration error, that the dosage was corrected. W1 also noted that a long term health issue of R1 appeared to improve after the correction. In addition, an interview with S1, had S1 recalling having to attend and In-service on the proper administration of the medicine in question after the error was discovered. A subsequent interview with S3, had S3 indicating knowledge of the medicine error and noting that they to, felt the correction in the error resulted in some improvement of R1’s long term health condition. Finally, because R1’s Service Plan indicates needing, “Maximum Assistance” with Medication Management, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A type A citation for CCR 87465(a)(4) is being assessed (see LIC9099-D) page Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due dates, may result in a civil penalty assessment. Exit interview conducted. Copy of report discussed and provided to Administrator Tedra Godfrey. A copy of Appeal Rights were left. Signature on form confirms receipt of documents. Continued from LIC9099-A A review of the call light record revealed that out of 90 calls for service on the AM shift of 03/23/26, call light response time took an average of 8 minutes and 48 seconds. Because Complainant reports that call light response time is no longer a primary concern and because of conflicting information about call light response times, this allegation is Unsubstantiated In addition, on 03/25/2026 CCL received a complaint alleging that staff at Ivy Park at “Do not keep the facility clean or sanitary”. Upon LPAs entry into the facility 04/01/2026 and again on 04/20/2026 I observed the facility to be clean, and without odors, in addition I observed multiple housekeepers cleaning and rolling well stocked cleaning carts throughout the property. On 04/20/2026 upon my unannounced entry into R1’s room, I again observed R1’s room to be clean and without odors and observed no troubling signs of improperly stored or disheveled personal medical devices. When R1 was asked if they had help to clean their room, R1 replied, “They (staff) do everything, they vacuum, change my bedding, wipe down things”. Similarly, when R2 was asked about housekeeping, R2 replied, “they will clean my room, vacuum, wash my clothes, sink and bathroom floor”, while R3 indicated, “The housekeeper, they come and do everything, they clean the linen, oh, they do everything!”. This LPA did receive a photo of a personal medical device being partially discarded or stored in a waste basket, but due to conflicting information about whether staff keep the facility clean or sanitary or not, this allegation is unsubstantiated Additionally, on 03/25/2026 CCL received a complaint alleging that, “Staff do not safeguard residents’ personal items”. The detail of the complaint reads, “The physician ordered a medical device for the resident, but the equipment repeatedly goes missing, leading the complainant to believe staff may be misusing or taking the supplies of the the specialty item.” An interview with R1 had R1 saying, that while at first it was thought that the stocks of the medical device were going missing, they were being stored by the Med-Techs. An interview with W1 raised uncertainty about where addition supplies of R1’s medical device were going and that W1 did not think they were being thrown away, but that a decision was made that supplies of the device would be stored and locked up by the Med-Tech staff. Continued on LIC9099-C Continued from LIC9099-C An interview with S3 indicated that the facility decided that the Med-Techs would both store and apply the device when R1’s private caregiver was not available to do so. In addition, an interview with R5 whose spouse uses a similar device reported no being concerned for the loss or storage of a similar device. Because conflicting information was received about the deposition of R1’s specialty medical device and because the facility developed a strategy to safeguard the specialty devices of R1, the complaint that “Staff do not safeguard resident’s personal care items is Unsubstantiated. Finally, on 03/25/2026 CCL received a complaint alleging that, “Staff do not adequately meet resident’s hygiene needs”. The detail of the complaint reads, “staff do not follow written or verbal care instructions, contributing to ongoing issues such as recurrent Urinary Tract Infection (UTIs) that the resident’s (R1) physician suspects may stem from improper cleaning after bowel movements” This LPA notes that R1 has the weekly help of a private caregiver and R1’s Service Planned signed by R1 on 11/23/2025 indicates R1 receives no help from staff at Ivy Park at Rockville for showering/bathing or grooming but R1 does require moderate assistance with transfers and maximum assistance with toileting needs from Ivy Park staff. LPA does not have physician notes that speculate on the recurrence of UTIs that may stem from improper cleaning after bowel movements. An interview with complainant had complainant speculating that R1 may have had as many as four (4) UTIs, over the last 10 months since a new management company took over at Ivy Park at Rockville, but complainant also offered that R1 had a severe UTI requiring hospitalization, before a new management company took over 10 months ago. Because of conflicting information about whether staff do, or do not adequately meet resident’ hygiene needs, the complaint that “Staff do not adequately meet resident’s hygiene needs” is Unsubstantiated. Continued on LIC9099-C Continued from LIC9099-C A finding that the complaint allegations are Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Administrator Tedra Godfreythe state’s words, verbatim · CDSS document, Jun 16, 2026 · control 21-AS-20260325150023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jun 26, 2026

87468.2 Additional Personal Rights of Residents in... Facilities:(a) in addition to... Section 87468.1...residents...shall...have the following Personal Rights: (4) To care, supervision, and services that meet their...needs and delivered by staff that are sufficient in numbers. This requirement was not met as evidence by: Based on, interviews and record review licensee did not comply with section cited above in ensuring that training in use of R1's medical device was performed by all staff administering R1s medical device.the state’s words, verbatim · CDSS document, Jun 16, 2026

Plan of correction: Licensee to submit self-certification that all staff who administer medical devices for R1 and other residents with similar devices have had hands-on training sufficienct to ensure proper application of devices like PureWick Incontinence devices, CPAP devices etc. A list of staff that will apply medical devices such as PureWick and CPAP devices, what was learned, the steps that staff will use to apply these specific device, as well as, the hands-on training they have recevied will be submitted to CCL by 06/26/2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 18, 2026

87465(a)(4) The Licensee shall assist Residents with self-administered medications as needed: This requirement is not met as evidence by: Based on record review and interviews The licensee did not comply with the section cited above. Licensee did not ensure that Resident 1 (R1) recieved a proper dose of ther Miralax per Physicians orders, which poses and immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 16, 2026

Plan of correction: Licensee to submit self-certification that R1 is now receiving a proper dose of their prescribed medications. Licensee to also submit the specific steps staff will take in measuring out Miralax specfically for R1, as well as all prescribed medications for Residents in general by by 06/18/2026

Type of visit: Office

An informal conference was conducted today in the Santa Rosa Regional Office. Present for the Santa Rosa Office were Licensing Program Manager Carla Martinez, Licensing Program Manager Bethany Moellers, and Licensing Program Analyst Star Stevenson. Attending virtually for the Oakmont Management group were Scott Carlson-Senior Vice President (VP) of Operations, Tedra Godfrey-Regional Operation Specialist and Administrator at Ivy Park at Rockville, Terry Ervin VP-Quality/Clinical, Jimmy Duong-Regional Health Services Director, Sue McPherson-Senior VP of Regulatory, Jennifer Sato-Senior VP of Health Services and Safoora Ahmed-VP of Memory Care Programming. The purpose of the informal office meeting was to discuss multiple complaints received by the Department. In 2025, there were eleven (11) complaints investigated and to date in 2026 there have been one (1) complaint investigation, and three (3) case management visits were the potential for financial or elder abuse were raised. Issues discussed during the meeting were: · Staff Training · Medication Errors · Personal Rights . Technical Support Programming Continued on LIC809C Continued from LIC809 The Regional Office learned today that in addition to the facility being 97% compliant with the on-line training with Relias, that an effort has been made to have more in-person training, a change that was apparently begun in earnest some 60 days ago. Today, we also learned that Ivy Park now has a full time Wellness Nurse to support training of the staff and the health and well-being of residents in care. In addition, Technical Support Programming (TSP) was discussed with the facility accepting a referral for TSP services. No deficiencies were cited during the office visit. A copy of today’s informal office meeting document will be delivered for signature and kept on hand for the facility file.the state’s words, verbatim · CDSS document, Jun 12, 2026

Allegation investigated: Staff did not provide adequate supervision

At approximately 10:45 AM Licensing Program Analyst (LPA) Star Stevenson arrived to deliver complaint findings of a complaint received by Community Care Licensing (CCL) on 12/18/2025. The complaint alleges that staff did not provide adequate supervision of Resident (R1) The complaint came, as a result of a fall that required hospitalization of R1. The complaint indicates that the complainant did not know the exact time of R1’s fall, and that R1 was a known fall risk and had fallen multiple times in the past and resided in the Memory Care section at Ivy Park at Rockville. Reporting party indicated having a conversation with an admitting Doctor at a local hospital that R1 may have been in the same position for an extended amount of time. The complainant’s primary complaint was that the facility knew R1 was a fall risk and did not provide R1 enough supervision to avoid R1 being in an awkward “found down” position for a prolonged time. continued on LIC9099C Unsubstantiated continued from LIC9099 A review of the Admissions Agreement for Ivy Park at Rockville states, “Our residents are free to spend time unsupervised in their apartments…and are not under continuous one-on-one monitoring. As a result, falls…will occur from time to time and that if (signers of the Admissions Agreement) are not comfortable with this environment, we suggested you consider a higher level of care.” An interview with complainant on 12/19/2025 indicated that the complainant was unaware of the supervision requirements for R1, but thought the R1 was to be “checked in on, every hour” A review of a Service Plan sent to R1’s responsible party for signature by email on 11/03/2025 indicates in a Special Care Needs section of R1’s Service Plan that R1” requires status (wellness) checks-3-4x each (8 hour) shift due to recent hospitalization, illness, medication change”. This LPA notes that three to four wellness checks in an eight-hour shift would indicate a check every 2 hours to 2 hours and 40 minutes. An interview with staff (S1) indicates that “staff round on memory care residents every two hours but that residents are allowed to wander their units and be as independent as possible.” An interview with staff (S2) indicates memory care residents might get checked on as frequently as every 30 minutes, but that “every two hours is the normal basis” A separate interview of staff S4 indicates, that “residents would be checked on every 2 hours unless they were a hospice resident and then they would be checked on every hour.” A review of R1’s Physician Report reveals R1 was not on Hospice resident. Additional review of R1’s Service Plan indicates, "R1 is a fall risk....R1 prefers to wear adult briefs all day/night. And R1 will toilet themselves when the need arises”, the same care plan indicates that R1 is “shy and likes to keep to themselves, while an interview with S2 indicated that R1 “preferred to have their door closed at night to reduce light and noise” with S2 noting that when R1 wakes up at night they might be confused and begin to perform actions of their previous career which could cause confusion among other residents in the memory care unit. LPA conducted three staff interviews which revealed that R1 was checked on at least every two hours and when found fallen on the floor, timely medical service was provided. LPA obtained staff schedule which appeared to be sufficient to meet the needs of residents in care. LPA was unable to obtain information during the investigation to support that the facility did not have adequate staff. continued on LIC9099-C continued from LIC9099-C Interviews with care staff indicate that wellness checks of residents were not required to be documented by Ivy Park at Rockville and that only Unusual Incidents, like the Incident Report related to R1’s fall were required documentation. Review of Incident Report filled out by S3 indicates 911 was called after 4:45 AM and that the responsible party of R1 was notified by phone at 5:00 AM and that the Primary Care Physician (PCP) was notified by phone at 6:00AM. A note next to these notifications indicate, “left voice mail” Based on facility record review and staff interviews it appears that the allegation of staff did not provide adequate supervision of R1 is Unsubstantiated. A finding that a complaint is unsubstantiated means, 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 This report was reviewed with Administrator Tedra Godfrey whose signature her denotes receipt.the state’s words, verbatim · CDSS document, Apr 20, 2026 · control 21-AS-20251218120655

Type of visit: Case Management - Other

At approximately 11:45 AM Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to follow up on an SOC341 (Suspected Elder Abuse) report received by the Community Care Licensing (CCL) on 02/24/2026. LPA met with Administrator Tedra Godfrey who assisted with today's Case Management visit. The SOC341 submitted by the Reporting Party (RP) alleges that resident (R1) had a deteriorating mental condition that questioned her ability to make informed decisions and also states that R1 and their adult child were at odds over R1's medical condition, and R1's ability to make informed decisions. The reporting party also reports that R1 had given conflicting statements or statements that were incorrect about their on-going health condition. Interview with the staff (S1) of Ivy Park at Rockville reveals that R1 seemingly had a change of condition and was initially sent out to a local hospital on March 13th, 2026 with with R1 then being placed on a 5150 hold. Discussions were had between S1 and R1's adult child as to the likelihood of increased care and increased care costs if R1 was able to return to the Ivy Park community, but R1 ultimately moved out of the Ivy Park community on 03/28/2026 with R1 and family seeking alternative placement with an integrated psych care component and higher level of care. No citations are being cited Report was reviewed with Administrator whose signature her denotes receipt.the state’s words, verbatim · CDSS document, Apr 1, 2026

Type of visit: Case Management - Incident

At approximately 09:45 AM Licensing Program Analyst (LPA) arrived unannounced to follow up on a phone call received on 01/15/2026 and a Unusual Incident Report (LIC624) received by this LPA on 01/21/2026 and forwarded to Community Care Licensing (CCL) from Executive Director Tedra Godfrey in which it was relayed to this LPA that a staff member (S1) had been found to have participated in CashApp financial transactions over the course of months with resident R1. Today LPA obtained conducted interviews. LPA may return at a later date to follow up on the above incident No deficiencies are cited. Report was reviewed with Executive Director Tedra Godfrey, whose signature her denotes receiptthe state’s words, verbatim · CDSS document, Jan 27, 2026

Allegation investigated: Staff do not allow the residents to choose their own pharmacy

At approximately 2:15 PM, Licensing Program Analyst (LPA) Stevenson arrived unannounced to deliver findings for this complaint Investigation regarding the above allegation and met with Executive Director Tetra Godfrey. On 12/03/2025 Community Care Licensing (CCL) received a complaint alleging that staff at Ivy Park at Rockville do not allow residents to choose their own pharmacy, with reporting party indicating receipt of a letter in late October 2025 stating that, as of February 1st, 2026 all residents would be required to have their medicines blister packed by Consonus Pharmacy and would be required to incur an increased cost to have “non-community pharmacy” (ie. Kaiser) medicines blister packed. A phone interview with S2 of the Oakmont Management Group overseeing Ivy Park at Rockville on 12/09/2025 indicates the goal of blister packing at the Ivy Park at Rockville community is to provide uniform medicine management to minimize mistakes and maximize patient safety while making it “as little of a net cost to residents as possible” Continued on LIC9099-C Unsubstantiated Continued from LIC9099 Review of a Service Plan received for R1 developed on 01/01/2025 indicates under the “Medicine Management” section that R1 receives full assistance with medicine management including, getting, “assistance with 10+ centrally stored medications” and “coordination with non-house pharmacy”, the service plan also indicates that R1 gets most of their medications filled through Kaiser, while R1’s family provides all over-the-counter (OTC) medicines. A follow up phone interview with S2 of the Oakmont Management Group overseeing Ivy Park at Rockville on 12/22/2025 and a follow up letter from S2 received 12/23/2025 indicates that responsible parties can provide medicines and pay themselves for prescription medicines to be re-packaged with Consonus Pharmacy or if a responsible party chooses not to sign a contract with Consonus Pharmacy for re-packaging, the community may cover the repackaging fees and pass the cost onto the residents through a monthly invoice. A blank Care Assessment Form provided to this LPA by S1 at Ivy Park at Rockville on 12/23/2025 indicates that as of 10/28/2025 the Executive Director (ED) will have discretion when assigning Pharmacy Care Points and costs for Kaiser and VA residents” Finally, a review of an Ivy Park at Rockville Resident and Service Agreement Section II (B)(4) provided to this LPA on 12/09/2025 indicates, “Fee Increase. Ivy may change any fees for General Services, Care Services, or additional items…upon (90) days written notice” as well as a Services section I(C)(13) under Additional Items and Services, “Ivy will make available…additional items and services at an extra charge, to be billed...on a monthly basis…any additional items or services that Ivy offers in the future” Because residents can continue with the pharmacy of their choice, and because the management at Ivy Park at Rockville has provided the necessary 90 days’ notice for a service fee increase, this allegation is unsubstantiated A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director Tedra Godfrey. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 21, 2026 · control 21-AS-20251203152056

Type of visit: Case Management - Incident

At approximately 2:15 PM Licensing Program Analyst (LPA) arrived unannounced to follow up on a phone call received on 01/15/2026 and a Unusual Incident Report (LIC624) received by this LPA on 01/21/2026 and forwarded to Community Care Licensing (CCL) from Executive Director Tedra Godfrey in which it was relayed to this LPA that a staff member (S1) had been found to have participated in financial transactions over the course of months with resident R1 and as a result, Ivy Park at Rockville had terminated S1 for violating the facilities policies prohibiting staff members from accepting "gifts" from residents. Today LPA obtained documents and conducted interviews. LPA may return at a later date to follow up on the above incident No deficiencies are cited. Report was reviewed with Executive Director Tedra Godfrey, whose signature her denotes receipt.the state’s words, verbatim · CDSS document, Jan 21, 2026

Allegation investigated: Fianancial Abuse

At approximately 12:55 PM, Licensing Program Analyst (LPA) Stevenson arrived unannounced to deliver findings for this complaint Investigation regarding the above allegation and met with Executive Director Tedra Godfrey. During this investigation, the Department requested and reviewed documents, conducted interviews, and made observations. On 11/13/2025 Tedra Godfrey of Ivy Park at Rockville began an internal investigation on the same day as receiving an email from complainant regarding the above allegation. Tedra Godfrey obtained a confession from S1 that they had stolen $180 and S1 was given a Disciplanary Action Notice and Employment Termination notice from from Ivy Park at Rockville issued the same day. In addition, an LPA interview with then former staff member S1 on 11/21/2025, had S1 admit to stealing $160 from R1 with S1 revealing they were not aware the amount was actually $180. A confession declaration was recieved by LPA from S1 indicating the theft of $160. Continued on LIC9099-C Substantiated Continued from LIC9099-C Interviews with the complainant and R1 revealed the suspicion of an earlier theft of a bottle of perfume and later, of minor snacks from R1's room. These suspected thefts were raised with the management on 08/11/2025. It was noted that the bottle of perfume that went missing from R1’s room could have been knocked into a trash can and simply taken out with the trash. At that time, without firm proof of theft, R1 was simply reimbursed by Ivy Park at Rockville for the missing bottle of perfume. Despite complainants documented concerns for a considerable theft at Ivy Park at Rockville, Community Care Licensing (CCL) received no Special Incident Report from Ivy Park at Rockville. Based on interviews, and record review and a declaration of guilt by S1 the allegation of financial abuse (Theft) is SUBSTANTIATED A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. (See LIC9099D) Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Executive Director Tedra Godfrey and Appeal rights were given.the state’s words, verbatim · CDSS document, Dec 9, 2025 · control 21-AS-20251112084547

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(10) · Plan of correction due date: Dec 19, 2025

1569.269 Enumerated Rights (a) Residents of a Residential Care Facility...shall have the following rights...(10) to be free from neglect, financial exploitation, involuntary seclusion... This requirement was not met as evidence by: Based on interviews and record review, the licensee did not comply in one (1) out of one (1) instance which poses a potential health safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 9, 2025

Plan of correction: Licensee to send self-certification that the have read regulation 1569.269 Enumerated Rights of the Health and Safety Code and to provide Community Care Licensing (CCL) of the specific steps/plan they will follow in the future for investigating potential thefts in the communty and the steps they will take to notify CCL when considerable thefts are suspected to have occured.

Allegation investigated: Staff did not provide resident's responsible party with itemization of additional fees charged.

At approximately 12:45 PM Licensing Program Analyst (LPA) Star Stevenson arrived to deliver findings regarding the above allegation and met with Tedra Godfrey-Executive Director. During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff did not provide resident’s responsible party with itemization of additional fees charged” The responsible party alleged that the facility would not provide them with a timely written update of additional care fees to be charged. LPA learned through record review that complainant had written notice of a “Legacy Care Fee” structure for residents in place when a new managment company took over, as well as access to an updated Admissions agreement and the Resident Assessment of care points assigned to R1. In addition, the responsible party had written notice as of April 1st, 2025, of the care fees that would be assessed Legacy residents under the new management at Ivy Park at Rockville. Continued on LIC9099-C Unsubstantiated Continued for LIC9099 Complainant acknowledged an understanding that care costs could increase and fluctuate depending on the care needs of R1. LPA learned through interviews that management had met with Complainant on 4 occasions, to go over care costs and answer questions. Complainant did report hearing conflicting expected care costs from S1 and S3, an assertion this LPA found to be credible. However, although the complaint was received on 11/04/2025, by 11/05/2025, LPA received an email from complainant noting they had on-line access to the amounts due for the next month and that, “The amount shown appears to be reasonable and manageable” Because of conflicting information on whether staff provided the resident’s responsible party with itemization of additional fees charged, the allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director Tedra Godfrey. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Dec 9, 2025 · control 21-AS-20251105083126

Allegation investigated: Staff do not ensure facility plumbing is in good repair

At approximately 10:30 AM, Licensing Program Analyst (LPA) Stevenson arrived unannounced to deliver findings for this complaint Investigation regarding the above allegation and met with Administrator Tetra Godfrey. During this investigation, the Department requested and reviewed documents, conducted interviews, and made observations. LPA determined that Ivy Park at Rockville has its own maintenance department that uses both an electrical plumbing snake, as well as manual snake for clogged or slow toilets. In addition, each housekeeper cart has a plunger on board to respond to clogged toilets, and the maintenance team keeps additional plungers on hand in the maintenance room. LPA obtained evidence of an in-house work order system called "TELS" being used to respond successfully to a clogged toilet on 08/16/2025 with resolution in18 minutes and again on 06/17/2025 with successful resolution in 13 minutes. Continued on LIC9099-C Unsubstantiated Continued from LIC9099 Staff interviews revealed that once a resident, a responsible party, friend or other staff identify a maintenance problem, the problem is immediately entered into the TELS system, and a member of the maintenance team sets out to fix the problem or will call an outside vendor if needed. Finally, an interview with R1 revealed that in fact, the maintenance staff had quickly responded to their toilet concern and that their toilet was never truly clogged but just slow to flush and R1 reports always being able to use their toilet and never having to use a toilet outside their room. LPA interviewed resident (R2) in an adjoining room to R1 which revealed they never had a problem with their toilet during the same time frame and that the maintenance team was quick to respond to their requests for repairs. Based on observations made, records reviewed, and interviews conducted, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Tetra Godfrey - Administrator Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Nov 6, 2025 · control 21-AS-20251014134258

Allegation investigated: Lack of adequate staffing resulted in resident care needs not being met.

At approximately 09:30AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to continue a complaint Investigation and delivered the findings regarding the above allegation and met with Administrator, Tedra Godfrey. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Lack of adequate staffing resulted in resident care needs not being met.” The complaint alleged that Resident 1 (R1) sustained multiple unwitnessed falls, bruises, and a possible heel wound while residing at the facility, and that inadequate staffing may have contributed to unmet care needs. LPA interviewed the Administrator and caregiver staff, who confirmed R1 had several falls, and that Special Incident Reports (SIRs) were submitted. R1 was described as independently mobile and on blood thinners, which may have contributed to bruising. A full body assessment was completed upon admission, and staff denied observing any heel wounds or unmet care needs during R1’s stay. Continued on LIC9099-C... Unsubstantiated Continued from LIC9099... There was no evidence that inadequate staffing contributed to R1’s condition or that resident care needs were not met. Based record review, interviews conducted, and observations made, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 21-AS-20250728162028

Allegation investigated: Staff are not allowing resident to have visitors

At approximately 12:45PM, Licensing Program Analyst (LPA) Deniz arrived unannounced to continue a complaint Investigation and delivered the findings regarding the above allegation and met with Administrator, Tedra Godfrey. During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff are not allowing resident to have visitors”. The complainant alleged that residents were being restricted from visiting with others. Specifically, Resident R1 indicated that on July 10, 2025, Visitor F1 was not permitted to visit due to concerns about maintaining a balance between both residents involved and the potential to trigger a fall/injury. Per interview, Staff S1 provided information regarding the facility’s visitor policy and explained how visitations are managed. S1 noted that F1 has short-term memory loss and may sometimes forget who they are visiting, or how to find the room of the resident they would like to visit, which has led to instances where F1 appeared confused or became lost during visits. Continued on LIC9099-C... Unfounded Continued from LIC9099... Interviews were conducted with both F1 and S1. F1 clearly expressed to the LPA that they are free to choose whom they visit, and that caregivers have consistently been helpful and supportive of visits. F1 emphasized that they make their own decisions regarding visitation and have not felt restricted by staff. Based on interviews, observations, and documentation reviewed, the investigation revealed that residents are allowed visitors and there was no evidence to support the claim that staff were preventing visitations, therefore the allegation is UNFOUNDED means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview was conducted and a copy of this report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Aug 29, 2025 · control 21-AS-20250710164113

Allegation investigated: Staff do not keep the facility free from a bug infestation

At approximately 2:30 PM, Licensing Program Analyst (LPA) Stevenson arrived unannounced to deliver findings for this Complaint Investigation regarding the above allegation and met with Administrator Tetra Godfrey. During file review, it was determined that on 10/16/2024 Community Care Licensing (CCL) received a former complaint that Rockville Terrace under Calson management that “facility has bed bugs” and that complaint was substantiated on 10/22/2024. Then on 11/07/2024 CCL received a compliant that, “staff did not ensure facility was free from pests (bed bugs) and that allegation was unsubstantiated on 02/11/2024. Then on 02/26/2025 CCL received a complaint that, “Staff do not keep the facility free from bed bugs” that alligation was also unsubstantiated on 04/15/2025. Finally on 08/11/2025, CCL received a complaint that "staff do no keep facility free from a bug (bed) infestation". Continued on LIC9099C Unsubstantiated Continued from LIC9099 During the course of this investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The most recent allegation of “Staff do not keep the facility free of pests.” Complainant stated that, "For months, since this facility has been taken over by Oakmont Management... residents rooms have been infested with bed bugs... no one has been putting any real effort to get rid of them:" Ivy Park at Rockville had been using Clark Pest Control company but moved to Pinnacle Pest Control in the hopes of having more aggressive pest control. LPA obtained records of Pinnacle Pest performing both heat treatments and spray treatments to affected rooms from 05/14/2025 to 08/13/2025. An interview with a representative from Pinnacle Pest Control also revealed their desire to have Ivy Park at Rockville use bed bug sniffing dogs to inspect the entire building. On June 11th, 2025, dog(s) from Harlem River Hounds identified nine (9) rooms which were subsequently treated by Pinnacle Pest Control. In addition, LPA learned that at least four (4) of the current maintenance/housekeeping staff were taught specific bed bug handling techniques by representatives from Clark Pest Control before current management took over in April of 2025. Pinnacle Pest Control expects to begin two hour training sessions with staff at Ivy Park at Rockville, but has not yet started. Finally, LPA observed on-going larger pest traps, typically used to target rodents strategically placed outside the building by Ecolab company. Based on observations made, records reviewed and interviews conducted, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Tetra Godfrey - Administrator Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 21-AS-20250811222737

Type of visit: Required - 1 Year

On 7/25/2025 at approximately 9:30AM, Licensing Program Analyst (LPA) Ali Deniz conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. LPA was greeted by Administrator, Tedra Godfrey. The facility is a two-story building licensed for 169 non-ambulatory and 30 bedridden residents, along with a hospice waiver capacity of 20. The facility currently provides care for 148 residents, 7 of which are receiving hospice services and a dedicated memory care unit. Annual fees are current. Required postings were observed. LPA continued with a tour of the facility with Administrator, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers found throughout the facility were found to be last charged on 06/02/2025 at the time of visit. Both smoke detectors and carbon monoxide detectors throughout the facility were interconnected and inspected by an outside agency with current certification dated 10/25/2024. Elevators were found to have current inspection certification with the date of 05/22/2025. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food delivered twice per week. Food stored in the kitchen was properly stored as per regulations on this day at the time of the visit. Facility closely monitors resident diets with appropriate dietary restrictions posted on kitchen walls. Toxins are stored in designated facility storage closets located throughout the facility. There was a supply of hygiene products and paper products available for residents. All residents’ apartments have lighting & appropriate furnishings. Water was measured at faucets in several residents’ private bedrooms and measured between 113.1- and 115.3-degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Continued on LIC809-C… Continued from LIC809… Medications located in medication rooms in both assisted living and memory care unit were found to be secured. LPA conducted a spot check of medications and found all administering and records to be in order. Medication management staff also conduct full medication record audits once per month. During the tour, residents observed interacting with staff in common spaces, watching television in their private bedrooms, participating in various activities with Activities Director and mingling in the dining hall with family and amongst each other. Residents are visited by family frequently and interact with one another in the dining area, common spaces as well as in resident private apartments. There is an ample amount of outdoor space and seating for residents on the front corridor and center patio for additional leisure. The facility conducts emergency disaster drills on a monthly, quarterly and annual basis all of which focus on various emergency types and include both staff and residents. Last monthly fire drill conducted on 07/11/2025 At approximately 12:45PM, LPA reviewed 10 resident records and found 10 of out 10 residents have current care plans, signed admission agreements, and physician's report on file. Medication records are thorough and contain physician's orders for each resident. LPA reviewed 6 staff records. 2 out of 6 records did contain documentation of completed training records as required, evidence of first aid training was current. Administrator stated the other 2 out of 6 staff are not working now and they won’t come back to work until they complete their training hours. 1 out of 6 staff have missed training ours. The administrator stated that when the management company changed three months ago the management company took all the staff and residents records with them. The facility is working on maintaining all the needed documents back again. (Technical Violation Issued). 1 out of 6 staff are working in the maintenance department and not required to have a first aid certificate per regulation. LPA reviewed the facility emergency disaster plan. Facility has supplies enough to operate for more than 72 hours in an emergency. Administrator, Tedra Richardson-Godfrey, Administrator Certification 7004281740 is valid through 10/21/2026. Updated copies of the following documents were requested for the facility file and are to be submitted to CCL by due date of 08/05/2025: LIC 308 Designated LIC 500 Personnel Summary LIC 9020 Register of Facility Client’s/Resident’s Copy/Proof of Updated Certificate of Liability Insurance No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.the state’s words, verbatim · CDSS document, Jul 25, 2025

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

Allegation investigated: Staff are not posting required documents in the facility for the residents

At approximately 1:00PM, Licensing Program Analysts (LPAs) Deniz and Felias arrived unannounced to initiate a Complaint Investigation regarding the above allegation and met with Administrator, Tedra Godfrey. During the course of the investigation, the Department made observations. There is an allegation of "Staff are not posting required documents in the facility for the residents.” Complainant alleged that the facility was not displaying required posters to inform residents and staff about important rights and regulations. These included posters outlining resident rights, complaint procedures, and information about the Long-Term Care Ombudsman." Continued on LIC9099C Unfounded Continued from LIC9099 LPAs conducted a walkthrough of the facility and found that the required postings were located in the resident mail room. Per conversation with Administrator, additional posters are also located in the staff room. Based on observations made, this allegation is Unfounded. A finding that the complaint is UNFOUNDED means that the allegation is false, could not have happened, and/or is without a reasonable basis. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 8, 2025 · control 21-AS-20250505101506

Type of visit: Office

On 5/7/2025, an informal meeting was conducted in the Santa Rosa Regional Office. Present in the meeting were Licensing Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Victoria Bertozzi, Licensing Program Analyst, Ali Deniz and representatives for the Oakmont Management Company, Terry Ervin, Shakeb Rafat, and Tedra Godfrey. Additionally, the following individuals were present virtually; Sue McPherson, Steven Walling, and Stephanie MacLean. Facility changed their management company to Oakmont Management Group LLC on 4/1/2025. The purpose of this meeting is to discuss concerns that have risen during multiple complaint investigations over the past year including, but not limited to, lack of communication, ensuring resident’s care needs are being met and an ongoing issue with bed bugs. With the new management company, executive director and team the intent is to discuss these ongoing concerns to ensure we move forward successfully, and the facility remains in compliance. The Department has offered Technical Support as a resource to the facility. A TSP referral will be made and they will reach out to complete the process. No citations are being issued today.the state’s words, verbatim · CDSS document, May 7, 2025

Allegation investigated: Staff do not keep the facility free from bedbugs Staff do not ensure the facility call system is properly operating

Licensing Program Analyst's (LPA's) Hansen & Deniz arrived unannounced for the purpose of delivering findings on the above complaint allegations. LPA's met with Regional Operational Specialist, Tedra Godgrey. This investigation included 3 unannounced site visits; a review of documents and statements from staff and witnesses. Complainant alleges staff do not keep the facility free from bedbugs. Complainant indicated they have never been to the facility but were told the facility has been dealing with bedbugs for quite a while and it's in the common areas and common area furniture. The facility has had Clark Pest Control in but has not had any effect or improvements. LPA obtained documents indicating Clark Pest Control conducted treatments for bedbugs on 11/18/2024-12/11/2024-1/7/2025 -1/9/2025 & 1/17/2025 including some with heat. As these treatments did not eradicate the issue, documents obtained, Ecolab Pest Elimination was hired and came out on 2/24/2025 & 2/25/2025 and serviced a few problem resident rooms. Continue on LIC9099C Unsubstantiated Continued from LIC9099 Interviews conducted with staff and residents revealed there have been no bedbugs found in the common areas. Although as a precautionary measure the common areas have been treated for bedbugs as well. There have only been a couple of rooms in AL upstairs that have been the issue. This allegation has been investigation in 2 other complaints 1) 21-AS-20241016223345 Facility reported September 23, 2024 was the first sighting of a bed bug in the facility, it was brought to the attention of staff who reached out to Clark Pest Control the same day. Clark conducted an inspection on September 24th. Residents and responsible parties in the areas impacted were notified via a letter, copy provided to the Department. September 26, 2024 Clark set-up the first heat treatment in two (2) rooms in the facility. On September 27, 2024, Clark returned to treat eight (8) additional rooms, they received a bio-spray treatment to ensure the bedbugs do not spread. On September 27, 2024 Clark did an in-service training with the maintenance and housekeeping supervisors who then trained their teams on what to look for and how to address a bed bug sighting among other topics. 2nd) 21-AS-20241107150613 - The facility has had a bed bug infestation first apparent in October of 2024. Facility management and housekeeping staff have followed the CA Dept of Public Health guidelines and have employed professional exterminators on a continuous basis throughout the period bed bugs have been present. This Agency has inspected for rodents on site visits conducted on 11/19/24; 12/03/24; and 01/28/2025 with negative results. Unsubstantiated as facility has continued to conduct follow up inspections and treatments – There was not sufficient information obtained to support a violation occurred as facility continues to conduct follow up inspections and treatments. Therefore, allegation staff do not keep facility free of bedbugsis Unsubstantiated Staff do not ensure the facility call system is properly operating- Complainant alleges the call system (Jeron) doesn't work/does not call to the pagers which has been going on over a year. On 3/4/2025 while at facility LPA observed and learned facility call bell system JERON, located in the nurses’ station, is older and does not print out a history of calls/when cords or buttons are pushed for help. LPA observed for 30 minutes system alarm going off that indicated room number and location (either bedroom/bathroom, etc) with a loud beeping noise that doesn't stop until staff push a button. Nurses station staff then call on walkie talkie to all staff for the nearest available to respond to resident, a staff then will reply they are handling. LPA observed calls being responded to in an appropriate amount of time. Complaint #21-AS-20241018122417 investigation revealed in part Facility call bell system is not able to pull a log showing calls and response times. An outside party conducting an unrelated visit to resident (R1) pulled the call bell and staff responded within 4 minutes. Findings were unsubstantiated. Although the allegation may be true, based upon the review of documents, observations made and statements provided, there is not a preponderance of evidence to prove, or disprove, the allegation. Therefore, the complaint is UNSUBSTANTIATEDthe state’s words, verbatim · CDSS document, Apr 15, 2025 · control 21-AS-20250226161300

Allegation investigated: Insufficient staffing to meet residents needs

Licensing Program Analyst (LPS's) Shannan Hansen & Ali Deniz arrived unannounced for the purpose of delivering findings on this complaint. LPA's met with Tedra Godfrey, Regional Operational Specialist. And discussed the disposition. Complainant has alleged that facility has insufficient staffing to meet the resident needs by not responding to request for help in an appropriate amount of time. Incident report received by Community Care Licensing (CCL) on 11/10/2024, occurred on 11/1/2024 in am when Resident (R1) pulled call bell cord and was found on toilet with fecal matter on hands and what appeared to be over ripe banana. When staff tried to help R1 get up from the toilet, R1 became defensive and R1 indicated they were not ready to leave. Staff returned later when R1 pulled cord again, finding R1 had vomit and fecal matter on them. Staff suggested to R1 to contact emergency personal, R1 declined. Staff asked responsible party who was on the cell phone with R1 if they could convince R1 to be seen by EMTs, responsible party indicated they would be there shortly. Complainant did not initially provide a date that staff did not respond in a timely manner and, when pressed, indicated 1/6/2025 & 1/9/2025. Continue on LIC9099-C Unsubstantiated Continued from LIC9099 Although documents obtained of incident reports for resident (R1) going to the hospital submitted to Community Care Licensing (CCL) do not support R1 went to the hospital on 1/6/2025 or 1/9/2025 or in January 2025 via 911 emergency. LPAs interview with responsible party revealed the two indicate dates referenced were doctors’ checkups, not visits to emergency. On 3/4/2025 while at facility LPA observed and learned facility call bell system JERON, located in the nurses’ station, is older and does not print out a history of calls/when cords or buttons are pushed for help. LPA observed for 30 minutes system alarm going off that indicated room number and location (either bedroom/bathroom, etc) with a loud beeping noise that doesn't stop until staff push a button. Nurses station staff then call on walkie talkie to all staff for the nearest available to respond to resident, a staff then will reply they are handling. LPA observed calls being responded to in an appropriate amount of time. Responsible party also informed incident R1 referenced, occurred on 11/1/2024. Staff schedule indicates on Am shift there were 4 caregivers & 2 Med techs, on PM shift there were 3 caregivers & 1 med tech, & on NOC shift, 2 caregivers & 1 med tech. Investigation revealed there was no information obtained to support a violation occurred. The incident complainant has referenced 11/1/2024 was regarding a complaint that had already been investigated from 11/2024 # 21-AS-20241105153420 found unsubstantiated. Interviews conducted and documents reviewed revealed there was insufficient evidence to substantiate the allegation. Although the allegation may be true, based upon the review of documents and statements provided, there is not a preponderance of evidence to prove, or disprove, the allegation. Therefore, the complaint is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Apr 15, 2025 · control 21-AS-20250113164020

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Shannan Hansen conducted an unannounced case management inspection and met with Interim Administrator Robert Coe, The purpose of this case management inspection is to follow up on two self reported incident reports submitted to Community Care LIcensing (CCL) 2/5/2025 & 3/3/2025. CCL received a self reported incident report reporting on 1/28/2025 resident (R1) was inadvertently administered another residents medication. Primary care physician (PCP) immediately notified along with family and monitored for any negative effects for 24 hours, no adverse side effects noted. Facility conducted in-service with staff and Consonsus pharmacy came out following day and shadowed pass. Facility has hired LVN to oversee medication room/care department. LPA followed up on a second medication error that occurred on 2/24/2025 when after medication review it was found R2 had been receiving incorrect dosage of medication since start on 2/21/2025. PCP on cite informed along with family. Indicated R2 showed no adverse side effects. Staff training in progress. This deficiency will be cited, 87465(a)(4) Incidental Medical and Dental Care- A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self-administered medications as needed, see LIC809D. Deficiencies cited from the California Code of Regulations, Title 22 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Interim Administrator. Appeal rights provided.the state’s words, verbatim · CDSS document, Mar 4, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 5, 2025

87465(a)(4) Incidental Medical and Dental Care- A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self-administered medications as needed, This requirement was not met as evidenced by: In review of records, R1 and R2 both had medication error incidents occur. Per review of records, the medication staff had in-service training on medication policies in regards to medication assistance to residents in care. Information obtained support that a violation had occurred regarding both resident incidents. This is an immediate risk to residents health &safety.the state’s words, verbatim · CDSS document, Mar 4, 2025

Plan of correction: LICENSEE/ADMINISTRATOR to send in written plan on how they will ensure compliance for meeting residents needs and medication training. First POC due date for written plan due 3/5/2025, with follow up by 3/7/2025 for proof of medication training..Submit to CCL by POC due date

Allegation investigated: Staff retained a resident that has a prohibited health condition Staff did not ensure facility was free from pests Medications not administered as prescribed Medications not properly stored Staff are not properly trained to use a hoyer lift

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. This investigation included 5 unannounced site visits; a review of documents and statements from staff and witnesses. It is alleged Resident (R1) has a prohibited health condition. Although R1 has a stage 3 wound, R1 is on Hospice which is allowed by regulation. The facility has had a bed bug infestation first apparent in October of 2024. Facility management and housekeeping staff have followed the CA Dept of Public Health guidelines and have employed professional exterminators on a continuous basis throughout the period bed bugs have been present. This Agency has inspected for rodents on site visits conducted on 11/19/24; 12/03/24; and 01/28/2025 with negative results. An audit conducted on 12/17/2024 indicated medications were properly stored and being administered as prescribed. Initially, a Hoyer lift was obtained for Resident (R2) but was not used by staff at the request of R2's family. In service training on Hoyer lift was scheduled for staff but cancelled when it was determined the lift would not be used. Although the allegations may be true, based on observation, records and statements, there is not a preponderance of evidence to prove or disprove the allegations. Therefore, the complaint is UNSUBSTANTIATED. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 11, 2025 · control 21-AS-20241107150613

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211 · Plan of correction due date: Feb 25, 2025

87211 Reporting Requirements. 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.. Death of any resident….Based upon record review and observation, this requirement not met as evidenced by: Death of R3 was not reported to Licensing by the facility. This poses a potential risk to the welfare of residents in care.the state’s words, verbatim · CDSS document, Feb 11, 2025

Plan of correction: Administration will review the requirements of 87211 and provide in service training to staff responsible for making death reports. Proof of training to be submitted to CCL by POC date in order to clear the deficiency.

Allegation investigated: Staff are mismanaging resident's medication

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with the Administrator and discussed the disposition. Through statements and document reviews it has been determined that R1 was prescribed Tramadol to be dosed 1/2 50 mg tab at bedtime as needed for pain but was administered 50 milligrams on several occasions in December, 2024, including 12/09, 12/15, 12/22; and some doses were given twice a day at times other than bedtime. Facility Administration has acknowledged the errors and has taken steps to retrain staff and place protocols in place to avoid future errors. Based upon the statements and documents reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Jan 21, 2025 · control 21-AS-20241226085057

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 21, 2025

87465(a)(4) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. *** Based on statements and document reviews, this requirement has not been met as evidenced by: R1 was given wrong dose of Tramadol on 12/09; 12/15; 12/22/2025. This posed an immediate risk to the health of R1.the state’s words, verbatim · CDSS document, Jan 21, 2025

Plan of correction: Cleared at time of visit. Administrator has provided extensive retraining for staff and put improved protocols in place.

Allegation investigated: Staff did not assist resident with transportation needs. Staff did not assist resident with care needs in a timely manner. Staff threatened resident.

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with **** and discussed the disposition. Complainant has alleged that facility staff are not responsive to Complainant's needs and cites having to wait for transportation to appointments, not responding timely to calls for assistance and making threatening remarks to Complainant. This investigation included a review of documents and taking of statements from parties and witnesses. Facility staff deny the allegations. A review of the facility policy regarding transportation for residents suggests that reasonable accommodations are made for the residents, including the Complainant. Complainant did not initially provide a date that staff did not respond in a timely manner and, when pressed, gave a date subsequent to the lodging of this complaint. This investigation found no evidence that staff have threatened the Complainant but did determine that exceptional efforts were made to accommodate Complainant's preference for particular staff to provide housekeeping services. Although the allegation may be true, based upon the review of documents and statements provided, there is not a preponderance of evidence to prove, or disprove, the allegations. Therefore, the complaint is UNSUBSTANTIATED. Report left. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 17, 2024 · control 21-AS-20241105153420

Allegation investigated: Resident care needs not being met Staff smoking marijuana on the premises Cleaning supplies accessible to residents in care

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint and met with *****.Complainant alleges resident care needs not being met, staff smoking marijuana on the premises and cleaning supplies accessible to residents in care. Complainant informed care needs are not being met not limited to hygiene and dental care. The 10-day complaint inspection was conducted on 8/29/2024 by LPA Hansen. Hansen made observations, obtained resident records, and conducted interviews. During the course of the investigation, it was revealed that resident (R1) was admitted to the facility 11/2022 and vacated 6/2024. R1’s current service plan signed on 11/12/2023 indicated that R1 was a level 1 needing minimal assistance with ADLs. Medical assessment obtained dated 7/10/2023 supported care needs and indicated R1 has been doing better with supervision. The Department received photos and a document signed by dentist dated 6/12/2024 indicating poor dental hygiene “might” be the cause for cavities and broken tooth noted. Subsequent interviews with staff, memory care coordinator and complainant on 11/19/2024 revealed information to support initial interviews conducted by Hansen. R1 was known to refuse hygiene care and staff would return at a later time to offer assistance. Continued on second page.... Unsubstantiated LPA obtained facilities substance abuse policy and interviews conducted did not support that staff are working under the influence. Memory care director informed there have not been any staff terminated for such behavior. Interviews revealed that toxins are stored outside of the dining area in janitors closest. Although, during inspection on 8/29/2024 LPA Hansen observed cleaning products under kitchen sink. They were removed immediately and stored in locked designated area. Interviews revealed that dining area is closed and not accessible after meals and residents are not left in the area alone. Although, toxins were observed there was staff supervision. The allegations noted above are found to be unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Report Left.the state’s words, verbatim · CDSS document, Dec 3, 2024 · control 21-AS-20240823135406

Allegation investigated: Staff did not prevent a resident from sustaining multiple falls while in care. Staff are not following resident's care plan.

Licensing Program Analyst (LPA) arrived unannounced to deliver findings on this complaint. Based upon information obtained during this investigation, which included interviewing staff and outside parties and record reviews, the above allegations are UNSUBSTANTIATED. Interviews and record review revealed resident listed as R1 requires “maximum assistance” with toileting, transfers, mobility, bathing (2x per week), dressing, grooming and medication management. R1 requires “moderate assistance” with coordination of outside agencies and oral hygiene. Service Plan dated 8/11/2024 corroborates the information above and details the assistance required, per Service Plan, R1 is a level 4. An updated Service Plan on record, dated 10/31/2024, shows R1 requires “maximum assistance” with toileting, transfers, mobility, bathing (2x per week), dressing, grooming, medication management and special needs – safety checks 4x per shift and rolling out of bed. R1 requires “moderate assistance” with coordination of outside agencies and oral hygiene. The updated Service Plan indicates R1 is a level 5 and details the assistance required. R1 had recently fallen out of their twin bed numerous times. The updated Service Plan ensures staff on each shift monitor R1 at least 4x per shift. Additionally, interviews with R1’s responsible parties (RP) and copies of correspondence between RP and facility Executive Director show RPs are in the process of obtaining a larger bed for R1 Unsubstantiated R1 to prevent R1 from rolling off of their bed. Based on interviews with R1, they feel staff are able to meet their needs and respond timely to requests for assistance and call bell. Facility call bell system is not able to pull a log showing calls and response times. An outside party conducting an unrelated visit to R1 pulled the call bell and staff responded within 4 minutes. Per R1’s Service Plan, R1 is to receive a bath 2x per week. R1 reported that staff assist with bathing and grooming, R1 did indicate refusal to bathe at times, so staff use a sponge bath which R1’s RP assists with obtaining. Outside parties interviewed indicated R1 appears clean and groomed, R1’s bedding and clothing are clean. Outside party interviewed visits R1 2x a week. Based on information obtained during this investigation, the allegations are UNSUBSTANTIATED meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. No citations issued this visit. Report left.the state’s words, verbatim · CDSS document, Nov 19, 2024 · control 21-AS-20241018122417

Allegation investigated: Facility has bed bugs

Licensing Program Analyst Leibert arrived unannounced in response to the allegation the facility has bed bugs. LPA met with Executive Director Carol Dowell. Based on a review of records which includes service orders and receipts from Clark Pest Control, interviews with staff and outside agencies the allegation of “facility has bed bugs” is SUBSTANTIATED. Facility reported September 23, 2024 was the first sighting of a bed bug in the facility, it was brought to the attention of staff who reached out to Clark Pest Control the same day. Clark conducted on inspection on September 24th. Residents and responsible parties in the areas impacted were notified via a letter, copy provided to the Department. September 26, 2024 Clark set-up the first heat treatment in two (2) rooms in the facility. On September 27, 2024, Clark returned to treat eight (8) additional rooms, they received a bio-spray treatment to ensure the bedbugs do not spread. On September 27, 2024 Clark did an in-service training with the maintenance and housekeeping supervisors who then trained their teams on what to look for and how to address a bed bug sighting among other topics. Clark Pest Control will be on property October 22, 2024 to conduct a follow-up visit and address any additional areas of concern. Substantiated The Administrator did follow reporting requirements and reported the bed bug situation via a Special Incident Report received on September 23, 2024 along with an email to LPA Hansen with a copy of a letter sent out to those residents impacted by the situation. During the investigation the Administrator provided the Department a list of preventative measures they are talking moving forward which include; checking rooms and common areas daily, shop vacuuming every other day, looking for new bug activity, picking up trash daily to ensure it is concealed in the dumpsters only, laundry is placed in plastic bags and a separate washing machine is used for any laundry from the rooms identified and treated, laundry is done using the hottest temperatures. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Oct 22, 2024 · control 21-AS-20241016223345

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303 · Plan of correction due date: Oct 24, 2024

87303 Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Based on records and statements, this requirement not met as evidenced by: Facility has presence of bed bugs in multiple rooms in one section of facility. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Oct 22, 2024

Plan of correction: Administrator will continue to work with Clark Pest Control to remedy the situation and ensure there is a long term plan going forward. Facility will ensure all staff (on all shifts), residents and their responsible parties are aware of the bed bug situation and steps to take if they identify a bed bug in their living unit and/or common areas. Administrator will submit plans to RO by POC date of October 24, 2024 along with copies of communication to all staff, residents and their responsible parties.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Cuadra and Loera arrived unannounced to conduct an annual required inspection and met with Carol Dowell, Administrator. There are 32 residents in Memory Care Unit and 108 residents in independent/assisted living rooms. Annual fees are current. Required postings were observed. LPAs/Administrator toured the facility at approximate 9:45am and observed the following: The facility was a comfortable temperature, and passageways were free of obstructions. Resident rooms are private or semi-private rooms, each with its own bathroom and furnished per regulation. A signal system has pull cords in bathrooms and living rooms. Multiple fire extinguishers are located throughout the facility and were last inspected February 2024. The required annual inspection of the central fire alarm/sprinkler system was last performed 8/25/23. There are also pull fire alarms located throughout the facility. The two elevators were last inspected 4/22/24. Water temperature was measured at 114.5, 113.9 & 107.1 which is within regulation. Last disaster drill was conducted on 8/15/24. Refrigerators and freezer measures were within regulation. There are at least two day supply of perishable foods and one week of non-perishable foods as required by regulation. Food handling and storage appeared to be within regulation. Toxins and cleaning supplies were observed locked and inaccessible to residents in care. Medication and their records were reviewed. LPAs initiated file review at around 10:30am. Ten residents and ten staff records were reviewed. All residents have current medical assessments and care plans. Three out ten staff did not have a health screening including TB test on file during today's visit. Administrator explained to LPAs that they have changed agencies that used to perform health screenings and they did not access to previous records (technical violation issued). Administrator certificate for Administrator Carol Dowell # 7005069740 expires 6/6/26. Administrator will submit updates of the following by 9/3/24: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), control of property and liability insurance. No deficiencies cited during today's visit. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Aug 20, 2024

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Resident continence care needs not being met

On 5/16/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Administrator, Carol Dowell. LPA toured the facility, interviewed Administrator and outside parties, reviewed resident medical and facility records and made observations during the course of the investigation. Complaint alleges resident (R1) continence care needs not being met. Based upon interview with outside Home Health Agency Lead Staff (I1), LPA found that there are multiple documented incidents in which R1 had been observed in soiled continence briefs when received by home health nurse (I2). In addition, R1's physician's report indicates that R1 has a bowel and bladder impairment condition indicating an increased level of supervision for R1's continence care needs which is documented on R1's Service Plan. Allegation, continence care needs not being met is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Appeal Rights Given Substantiated In addition, based upon R1's physician's report, there are no indications of R1 requiring continuous bed care or repositioning to prevent wounds based on level of care at the time of wound observations. Due to inconsistent and contradicting information gathered, the allegation is found to be unsubstantiated. Complaint alleges facility violated the personal rights of resident, R1 due to inappropriate request for hospice placement. Based upon interview with Administrator and outside parties, it was found that inconsistencies of communication between Administrator and outside parties (I3), convoluted determining the diagnosis stage of R1's wound and whether the wound was considered a prohibited health condition; stage 3 or higher. Due to inconsistent information gathered, the allegation is found to be unsubstantiated. A finding that the complaint allegations, neglect/lack of supervision resulting in pressure injury and personal rights are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, May 16, 2024 · control 21-AS-20240220181337

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466.2 · Plan of correction due date: May 17, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (4) To care, supervision, and services that meet their individual needs...This requirement was not met as Based on resident record review and interviews with outside parties (I1), facility did not provide appropriate supervision and assistance with R1's continence care needs. This serves as an immediate health & safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: Administrator to provide in-service training for all caregiving staff to review continence care protocols. Administrator to submit scheduled training date to CCLD by POC date 5/17/2024 and submit completed signed training log to CCLD by POC date 5/31/2024. Administrator to provide in-service training to review continence care protocols and submit signed training log to CCLD by POC date 5/31/2024.

Allegation investigated: Staff did not provide proper medication assistance to resident in care

Licensing Program Analyst (LPA), Farhaan Saragi arrived unannounced at Rockville Terrace Senior Living for the purpose of delivering complaint findings. LPA was greeted at the door by, Assistant Administrator, Hannah Richardson, and was granted access into the facility. Administrator arrived 30 minutes later. During the course of the investigation, LPA Sarangi reviewed residents Medication Assessment Records, facility records and interviewed staff. Complaint alleges that Staff do not provide proper medication assistance to resident in care. Based on an observation of the Medication Assessment Record (MAR) that was conducted, LPA learned that during the months of April 2023 there were gaps in the administration of medication for multiple medications which included eye drops for Resident #1 (See LIC 9099D). A former staff member missed the administration of eye drops on April 19-23, 2023, April 27 & 28, 2023 and April 30, 2023. An interview with the Administrator confirmed the missed medication administration for said dates. (Report continued on LIC 9099C) Substantiated During a review of incident reports for the month of April 2023, the facility did not report the incident to CCL. (See LIC 809) Furthermore, LPA reviewed a sample of residents Medication Assessment Records (MARS) to ensure that there is no pattern of not administering medication. MARS for the sample of residents reviewed were appropriate with time and dates indicated. LPA educated the Assistant Administrator on the importance of administering medication that is prescribed by a physician. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Assistant Administrator.the state’s words, verbatim · CDSS document, Oct 4, 2023 · control 21-AS-20230918161317

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 5, 2023

87465(a)(4) Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on an observation of the Medication Assessment Record (MAR) that was conducted, LPA learned that during the months of April 2023 there were gaps in the administration of medication for multiple medications which included eye drops for Resident #1. A former staff member missed the administration of eye drops on April 19-23, 2023, April 27 & 28, 2023 and April 30, 2023. An interview with the Administrator confirmed the missed medication administration for said dates. This is an immeidate Health, Safety and Personal Rights risk to the residents in care.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: Plan of Correction (POC) shall include self-certification of an LIC 9098 understanding the regulation. In addition, Administrator/Licensee shall provide a plan for future compliance and conduct staff training on administering and documenting medication assessment records. POC due date for the Plan for Future Compliance will be on October 5, 2023. Training POC due date on October 11, 2023.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Farhaan Saragi arrived unannounced at Rockville Terrace Senior Living for the purpose of Case Management-Other inspection. LPA was greeted at the door by, Assistant Administrator, Hannah Richardson, and was granted access into the facility. Administrator arrived 30 minutes later. During the course of the investigation that was initiated on September 28, 2023, LPA reviewed incident reports for the month of April 2023 and learned that the facility did not report the Missed Medication Administration to CCL (See LIC 9102-Technical Violation). LPA educated the Assistant Administrator on the importance of 87211-Reporting Requirements as it relates to reporting incidents to CCL. No deficiencies were cited during this Case Management-Other inspection. LIC 9102-Technical Violation was issued to the facility. Exit interview was conducted, and a copy of this report was signed and given to the Assistant Administrator.the state’s words, verbatim · CDSS document, Oct 4, 2023

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Rockville Terrace Senior Living for the purpose of conducting a Case Management-Other inspection. LPA was greeted at the door by Assistant Administrator, Hannah Richardson and was granted access into the facility. Assisted Living Resident Care Coordinator, Josephine Garcia Evans was also in attendance. Administrator arrived 1 hour later. During the Case Management-Other inspection, LPA interviewed the staff member regarding an incident that occurred on September 27, 2023, interviewed an outside agency, interviewed a resident in care and reviewed resident and facility records. LPA learned of no concerns regarding any staff members at the facility. Exit interview was conducted, and a copy of this report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Sep 28, 2023