Ivy Park at Sabre Springs

Allegation investigated: Unlawful eviction.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced 10-day visit to initiate a complaint investigation and deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Rob Daynes. On 07/31/2026 it was alleged that the licensee unlawfully evicted a resident. The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff, resident, outside source, and records review. Relevant staff members who were interviewed informed that R1 had been exhibiting extreme combativeness and aggression over the past months and they had been trying to get R1 properly evaluated. Staff stated that the medication R1 was prescribed for agitation actually increased their agitation to the point of significant physical violence, self harm, and threats to kill staff. R1 was sent out to two hospitals during the timeframe of concern in an attempt for R1 to be evaluated, returning to the facility both times, on 07/27/2026 and 07/30/2026. Upon both discharges, R1's behaviors of aggression to self and staff continued when being assisted with Activities of Daily Living (ADLs). (Continued on LIC9099 p.2) Unsubstantiated (Continued from LIC9099 p.1) Facility staff informed the hospital that it would not be safe to discharge R1 back to the facility due to their self-harming behaviors and persistent attacks toward care providers; staff requested a medication adjustment with observation period. Staff informed that the medication request was granted but not the observation period. R1 was sent back to the facility on 07/30/2026. Staff stated that R1's physical aggression episodes continued immediately upon their return to the facility. Staff maintained that there was not a plan for R1 to move to a different facility and the intention was always for R1 to return after the medication evaluation. Staff informed that after the second attempt for a medication/behavioral evaluation, R1's family was provided with placement resources by an outside entity and the family initiated for R1 to move to a different facility. During the unannounced facility visit LPA attempted to interview R1. R1 was present at the facility at the beginning of the visit, however they were moved to their new facility during the visit. LPA spoke with the person responsible for making decisions for R1's care. The responsible person informed that R1 was having behavioral issues and went to the hospital for an assessment, but the hospital did not keep R1 for a full evaluation. The responsible person confirmed that R1 returned to the facility. LPA reviewed the following relevant records for the investigation: facility care notes, communication between the facility and R1's doctor, shift reports, text messages, and facility census records. The records corroborated staff statements regarding R1's physical/verbal aggression, facility attempts to address R1's change in condition, communication with R1's family, R1's admittance/discharges from two hospitals in an attempt for R1 to receive a behavior evaluation, and R1's return to the facility from both hospital visits. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Rob Daynes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 6, 2026 · control 08-AS-20260731093053

Allegation investigated: Licensee did not assess residents according to their level of care. Licensee did not ensure resident records were complete and current.

The following determination of findings have been made by Licensing Program Analyst (LPA) Nacole Patterson regarding the above allegations. This report was mailed to the Licensee. On 03/11/2025 it was alleged that Licensee did not assess residents according to their level of care, and Licensee did not ensure resident records were complete and current. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, resident, outside sources, and records review. Staff interviews were consistent regarding the facility's assessment procedures for residents. Staff informed that the only resident with an assessment adjustment during the timeframe of complaint was Resident 1 (R1). The assessment procedures outlined by staff were consistent with R1's onboarding and assessment documents. Staff informed that while R1 was appropriately assessed to be placed in the Assisted Living section of the facility, R1 experienced a change of condition shortly after admission showing cognitive decline. Staff informed that the facility continued to monitor R1 and enacted safety measures that consistently matched R1's level of acuity and cognition. (Continued on LIC9099 p.2) Unsubstantiated (Continued from LIC9099 p.1) R1 was interviewed privately during and unannounced facility visit. R1 was observed to have long-term memory recall during interview, however R1 exhibited some confusion about present day, such as how long they had lived at the facility. R1 was oriented to person, place, and partially time. R1 had a safety monitoring device on their person and understood what it was for and that they could not leave the facility on their own. While R1 exhibited some memory issues, they did not present as an inappropriate fit for the Assisted Living section of the facility with the safety device in place. Review of facility records showed that R1 moved into the facility on 02/19/2025. The assessments and onboarding paperwork for R1 were observed to be dated on 02/19/2025 or earlier. The documents dated after the 02/19/2025 were related to R1's change in behavior that presented after admission. The facility's assessment documents were consistent with the assessment documents submitted by R1's Responsible Person and doctor. This showed that R1 was accurately assessed to live in the Assisted Living section of the facility based on the information available at the time of admission. Incomplete admission and/or assessment documents were not found. LPA contacted an outside advocacy agency familiar with the facility. The agency representative informed that they had no concerns regarding the facility. Requests for additional information from the concerned party were not responded to. LPA observations during interview with R1 were consistent with the documentation regarding R1's level of cognition. During subsequent facility visits for unrelated investigations, LPA observed that R1 had moved into the Memory Care section of the facility. This showed that the facility continued to evaluate and adjust R1's level of care over time. The evidence showed that the facility conducted numerous assessments to evaluate R1's fit for the facility. While R1 did suffer mild cognitive impairment, precautions were in place for R1 to live safely in the Assisted Living section. The evidence additionally showed that upon R1 exhibiting a change in condition, facility staff assisted R1 with additional evaluations and communicated the changes to R1's Responsible Person and doctor. R1 was moved into the Memory Care section of the facility as their cognitive impairment progressed. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. This report and the Licensee/Appeal Rights (LIC9058 03/22) were mailed to the Licensee.the state’s words, verbatim · CDSS document, May 31, 2026 · control 08-AS-20250311114348

Type of visit: Office

Licensing Program Analyst Nacole Patterson, Licensing Program Manager Sabel Martinez, and Regional Manager Jerry Romero met with Executive Director Rob Daynes and facility representatives to address previously cited deficiencies related to resident personal rights. During the meeting, Regional Manager Jerry Romero reviewed the circumstances surrounding each deficiency and discussed the facility’s current practices, corrective actions taken, and plans to prevent recurrence. The licensee and representatives were provided clarification on regulatory requirements and were reminded of their responsibility to ensure staff are trained and procedures are consistently implemented. The licensee expressed commitment to improving internal oversight, maintaining compliance, and ensuring resident safety. The department and the licensee jointly reviewed expectations moving forward and were advised that should any serious violations occur within the facility, a non-compliance conference may be held. No deficiencies were cited during today's office meeting. An exit interview was conducted with Executive Director Rob Daynes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 26, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Business Office Director Kat Mills and Executive Director Rob Daynes. The facility's license shows a maximum capacity of 100 non-ambulatory residents, 8 (eight) of whom may be bedridden. All rooms approved for bedridden. 3rd and 4th floor approved for delayed egress. Hospice waiver approved for 20. During today’s inspection there were 97 residents in care. LPA and Executive Director Rob Daynes toured the interior and exterior of the facility and inspected a sample of rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Executive Director Rob Daynes, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Rob Daynes to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were email.the state’s words, verbatim · CDSS document, Mar 24, 2026

Allegation investigated: Licensee did not allow resident to receive phone calls.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Rob Daynes. On 11/12/2026 it was alleged that Licensee did not allow Resident 1 (R1) to receive a phone call. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Staff interviews revealed that initially, an instruction existed for staff not to inform a specific outside source that R1 lived at the facility due to safety concerns. Interviews further revealed that the facility later changed this instruction, informing staff that if the outside person called, they must inform R1 and allow them to accept or deny the phone call. Staff stated that during a recent All-Staff meeting, training was provided regarding residents' personal rights to receive or reject phone calls. Outside source interviews revealed that upon calling the facility, the outside source in question was told that R1 did not live there. (Continued on LIC9099 p.2) Substantiated (Continued from LIC9099 p.1) Outside source interviews revealed that for subsequent calls, R1 was informed of the calls and the outside source was able to speak to R1 via phone. Records review corroborated staff statements regarding the initial instruction for staff not to inform the outside source that R1 lived at the facility. Records additionally reflected the subsequent changes made by the facility regarding R1 being allowed to make the decision to receive or reject incoming phone calls. R1 was interviewed during an unannounced facility visit. Due to cognition, R1 was observed to have partial orientation. R1 informed that if they received a phone call from the outside source they would accept it. Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation occurred, and is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Rob Daynes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from LIC9099 p.1) During an unannounced facility visit LPA directly observed a posted visitation sign in the main hallway that stated the facility's visitation policy. The visitation policy stated that residents can receive visitors at any time, provided that the visitors respect the rights of residents and staff and abide by visitation policies during the visit. R1 was interviewed during an unannounced facility visit. Due to cognition, R1 was observed to have partial orientation. R1 informed that they have received visits from outside parties at the facility but was not able to recall specific information or dates. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Rob Daynes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 08-AS-20251112131132

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(14) · Plan of correction due date: Jan 28, 2026

"Residents in all residential care facilities for the elderly shall have all of the following personal rights:...to both make and receive confidential calls." This requirement was not met, as evidenced by: Based on interviews and records, the Licensee did not allow a resident (R1) to receive a phone call, which posed a potential pesonal rights risk to 1 of 97 residents in care.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: On 11/19/25, 1/14/26 and 1/21/26, the Executive Director conducted personal rights training with all staff regarding residents' rights to phone calls and visitation. The sign-in sheets were provided to LPA as proof. This satisfies the plan of correction.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Executive Director Rob Daynes to discuss the purpose of the visit. Today's visit is in response to the self-report of Resident 1 (R1) accusing a staff member, S1, of handling them roughly. LPA conducted a wellness check at the facility and interviewed staff and residents. No deficiencies were cited or observed on this date. An exit interview was conducted with Executive Director Rob Daynes, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Nov 19, 2025

Allegation investigated: Staff did not treat resident(s) with dignity. Staff did not respond to residents' call buttons in a timely manner. Staff did not provide adequate supervision to residents(s).

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Rob Daynes. On 05/08/2025 it was alleged that staff did not treat resident(s) with dignity, staff did not respond to residents' call buttons in a timely manner, and staff did not provide adequate supervision to residents(s). The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, outside sources, and LPA direct observations. Regarding the allegation, "Staff did not treat resident(s) with dignity", it was alleged that specific staff members were observed yelling at residents and handling them roughly. (Continued on LIC9099 p.2) Substantiated (Continued from LIC9099 p.1) Staff interviews corroborated this allegation, as staff who had observed this issue informed witnessing specific caregivers exhibiting impatience with memory care residents by raising their voices or stating they would not help them. Staff interviews additionally revealed observations of a staff member hitting the hands of a resident during care when the resident was resisting, forcing a resident's hands from a bed rail and moving faster than the resident wanted to go, ignoring their protests. Additional staff observations included a staff member mocking a resident and responding to a resident in a way that escalated the resident's behavior instead of attempting to calm the resident down, a staff member using inappropriate supplies to clean a resident, improper protocols while changing a resident that did not maintain their dignity, and a group of staff not being respectful of a resident's change in condition. During interviews staff were asked if the situations were elevated, which some staff affirmed that they had notified management when the incidents occurred. Staff additionally mentioned that the incidents occurred during times where no management, families, or agency visitors were present. One incident was noted regarding an accusation against a staff member that had been previously investigated by the Department through case management and found to be unsubstantiated. Facility records were not found to show that the incidents named by staff were documented in staff files or that the staff were reprimanded for the incidents named. Outside sources were interviewed regarding the allegation. No outside sources had observed dignity issues by staff toward residents. Regarding the allegation, "Staff did not respond to residents' call buttons in a timely manner", it was alleged that residents experienced long wait times for staff assistance when they pushed their pendants. Staff interviews provided differing expectations of facility policy wait times, ranging from 7 to 20 minutes. Five (5) staff stated that the response times were reasonable and/or between 7-15 minutes. Five (5) staff stated that the response times were too long, observing wait times in excess of 30, 40, 60, 90 minutes, and three (3) hours. Staff stated that the that the response delays occurred on certain floors or during certain times of day. (Continued on LIC9099 p.3) (Continued from LIC9099 p.2) Staff informed that some of the reasons for the wait times had to do with the pendant technology, the phones not working to know that a resident had paged, or not having a magnet to clear the phone. Other staff interviews revealed that some residents over-utilized their pendants, did not understand how to use them/pushed them in error, misplaced them, or would not allow staff to clear it. Staff who informed long wait times informed that there was no reasonable explanation for the delayed responses they witnessed, and that the staff members observed were on their personal phone instead of attending resident calls. Staff stated that while not every call was legitimately missed, the overall response time was too long and that management was aware. Staff additionally stated that the response times and assistance from management has recently improved with the new Memory Care Director. Review of facility pendant logs for the month of May 2025 revealed that a pattern of extended wait times did exist, corroborating the allegation and staff interviews. Excluding outliers, the pendant log showed that approximately 126 (one hundred twenty six) calls had response times greater than 20 (twenty) minutes. Outside source interviews were mixed regarding the allegation, as some sources informed that their respective residents were not cognizant to utilize their pendant, other sources stated that their residents did express to them that the response times were slow, and further sources informed not being concerned about response times or not having observed the response times. Resident interviews confirmed the wait times, as resident stated that they had waited 20 minutes or greater, or pushed their pendant and no staff responded to their call. Regarding the allegation, "Staff did not provide adequate supervision to resident(s)", it was alleged that staff were observed sleeping on shift and there were times when residents were not being supervised. Staff interviews corroborated this allegation, as nine (9) staff informed of being aware and/or directly observing staff sleeping on shift or being on their phones in lieu of assisting residents. During interviews, clarification was made to confirm that these instances negatively affected resident supervision, or that there were no staff actively supervising the residents, which was affirmed. Staff informed that an internal policy existed restricting staff from being on their phones while working the care floors, however not all staff adhered to this rule. Staff offered specific observations such as entering a care floor and observing all caregivers sitting in the corner on their phones, a caregiver on their phone with earbuds in both ears while not on break, a caregiver falsely stating where they were on two occasions while 2-person assist residents were waiting for assistance, and staff sleeping on shift while not on break. (Continued on LIC9099 p.4) (Continued from LIC9099 p.4) Interview information showed that a pattern existed on certain resident floors during certain times of the day. Review of facility records revealed Disciplinary Action Notices for staff who were found sleeping on shift and staff who left their care floor either unattended or low staffed. These staff were given written warnings and/ or terminated due to this behavior. Additional records revealed staff members being questioned by management for going on break at the same time with no supervision of residents on the floor. Outside sources were interviewed regarding the allegation. No outside sources had observed inadequate supervision by staff, however, the outside sources confirmed during interview that they did not visit their respective residents during the timeframe in question. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violations occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Rob Daynes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from LIC9099 p.1) Staff interviews did not corroborate this allegation, as staff consistently stated that R1's medical conditions made it very painful for them to be repositioned, resulting in R1 resisting and refusing care. Staff stated that they directly observed staff and R1's Hospice agency attempt to consistently reposition R1 to avoid pressure injuries, however R1's resistance prevented them from doing so each time. R1's Hospice agency corroborated staff statements, informing that staff consistently attempted to turn R1 at regular intervals and also assisted them with turning R1 during visits, however R1 experienced progressive agitation due to pain, preventing them from being turned. This outside source additionally stated that R1's physical condition combined with becoming bed bound made their pressure ulcers inevitable, and the sores did not exist prior to R1's end stage condition. R1's Responsible Person informed that staff repositioned R1 as much as R1 would tolerate and were not neglectful in attempting to turn R1. Interviews with outside source medical professionals for other residents revealed that staff consistently turned other residents who were also at risk for pressure sores. R1 was unable to be interviewed due to passing away. Records review revealed that R1 was receiving Hospice services. Shift reports, care notes, and shower skin sheets during the timeframe of complaint showed that staff tended to R1 regarding repositioning. Regarding the allegation, Staff did not ensure residents' incontinence needs were met", it was alleged that Memory Care residents were not being assisted with toileting. Staff interviews were mixed regarding this allegation, with a majority of staff informing that toileting assistance was consistent and timely. Staff informed that toileting protocol was to assist or ask residents to use the bathroom approximately every two (2) hours. Some staff stated that residents in wheelchairs were not toileted as often as ambulatory residents, and other staff stated that communication between shifts resulted in confusion on when residents were being changed. Additional staff stated that at times the timelines were slightly extended, however, ultimately all residents were changed. Staff additionally noted that some residents refused to be assisted with toileting every two hours or had a behavior of inappropriately toileting around the building. Outside sources interviewed did not express concerns regarding residents being assisted with incontinence care at the facility. One outside source noted that their respective resident tended to be combative when being given assistance. All outside sources informed of directly observing staff assist residents to the bathroom. (Continued on LIC 9099 p.3) (Continued from LIC9099 p.2) During unannounced facility visits LPA directly observed caregivers assisting residents with ambulating to the bathroom, and privately changing residents with incontinence briefs. Regarding the allegation, "Staff did not observe residents for change in condition", it was alleged that staff did not follow Resident 1's care plan or notice when pressure sores began to develop. Staff interviews were mixed regarding this allegation, with a majority of staff stating that staff monitor residents for changes in condition and elevate the changes per protocol. One staff noted that a Medication Technician (Med Tech) elevated sores found on a resident's feet that had gone unnoticed by caregivers, indicating that the caregivers were not changing the resident's socks daily. Another staff offered that caregivers could fill out the communication logs in more detail, but did not state a specific incident where lack of detail resulted in and issue for a resident. All other staff informed that communication about residents' conditions were documented and elevated to management as well as residents' care providers and responsible parties. Outside sources unanimously stated that the facility communicated changes in condition for residents. One responsible party noted that the facility had contacted them the day of interview letting them know that their resident was running low on a supplemental meal. No outside sources expressed concerns regarding the communication of changes in condition. Review of facility records revealed resident charting notes of physical and behavioral changes that were documented and elevated to residents' doctors, hospice agencies, and responsible parties. The charting notes also noted when residents were temporarily placed on alert charting for increased monitoring. Regarding the allegation, "Staff did not assist residents with personal care needs", it was alleged that residents were not being assisted with grooming and changing of clothes on the memory care floors. Staff interviews were mixed, as some staff informed that they did not observe un-groomed residents. Other staff confirmed that memory care residents were not consistently being helped with grooming tasks such as teeth/denture brushing, hair brushing, changing soiled clothes, and washing their faces. Staff interviews were consistent in that showering was being done with residents. Staff consistently stated that if a resident did not receive grooming help, the primary reason was due to refusals, including refusals to Hospice and/or Home Health providers. (Continued on LIC9099 p.4) (Continued from LIC9099 p.3) While some corroboration existed regarding this allegation, less than half of the staff expressed concern regarding residents not being assisted with personal care needs. Outside sources did not corroborate the allegation, informing that residents appeared groomed during visits with their respective residents. Outside sources did not express concern regarding resident grooming at the facility. Regarding the allegation, "Staff did not provide resident(s) with housekeeping services", it was alleged that resident rooms were not being maintained clean by staff and that resident laundry was not being consistently washed. During interviews staff refuted this allegation, consistently informing that resident rooms were cleaned by housekeeping and caregivers. One staff member interviewed believed another staff may have covered up a resident's dirty sheets on a non-housekeeping day instead of washing them. One staff noted that if a shift is particularly busy there may be a delay in switching the laundry from the washer to the dryer, however this was a rare occasion and the resident's clothes were still washed by the end of the next shift. Staff also noted that due to cognition, sometimes Memory Care residents hid their clothes in unlikely places and caregivers did not see the items to collect for washing. Outside source interviews revealed no concerns regarding resident laundry. Outside sources consistently stated that the facility was clean, organized, and that resident laundry was regularly washed. During unannounced facility visits LPA directly observed a sample of resident rooms and common areas. LPA did not observe areas that were disorganized, unkempt, or in disarray. LPA did not observe any resident rooms that indicated laundry had not recently been washed. Regarding the allegation, "facility smelled malodorous", it was alleged that the Licensee did not address the smell of incontinence on a Memory Care floor. Staff refuted the allegation during interviews, informing that while there was a smell of incontinence due to two residence having a behavior of inappropriately toileting, management made timely attempts to fix it. Staff stated that the carpets and furniture were cleaned after each incident, and the residents' care plans were updated regarding the behavior. (Continued on LIC9099 p.5) (Continued from LIC9099 p.4) Changes of condition were communicated to the residents' responsible parties and medical providers, and the floor in the residents' room was replaced with vinyl flooring instead of carpet. Staff did not express concern regarding the Licensee's attempts to rectify the issue. Review of facility records corroborated staff statements, revealing a vinyl flooring invoice for the residents' room in question. Shift reports and care notes during the timeframe in question revealed instructions for the residents to be assisted with toileting every hour, and before and after meals. Shift Report documents also showed that staff communicated when the residents had inappropriate toileting episodes and included requests for staff to keep the residents' floor clean/dry. Four (4) of five (5) outside sources advised not observing any malodor at the facility. One outside source confirmed observing the malodor but stated that the facility cleaned the carpets, updated the flooring, and increased toileting for the residents in question in attempts to rectify the issue. During an unannounced facility visit LPA Patterson directly observed the malodor in question, however, the carpets were actively being cleaned during the observation. LPA observed the new vinyl flooring in the room in question, corroborating management statements that the flooring had been replaced from carpet to vinyl. During subsequent unannounced visits LPA Patterson observed the memory care floor in question to be free from malodor or signs of inappropriate toileting. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Rob Daynes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 08-AS-20250508132716

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 31, 2025

a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met, as evidenced by: Based on interviews and records review, Licensee did not ensure residents were accorded dignity in their personal relationships with staff. This posed a potential personal rights risk to 96 of 96 persons in care.the state’s words, verbatim · CDSS document, Oct 1, 2025

Plan of correction: Executive Director agreed to conduct personal rights training for all care staff and to submit the training sign-in sheet(s) to LPA by the POC due date, as proof.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Oct 31, 2025

(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications... This requirement was not met, as evidenced by: Based on interviews and records review, Licensee did not ensure resident personal assistance was met as needed. This posed a potential safety risk to 96 of 96 persons in care.the state’s words, verbatim · CDSS document, Oct 1, 2025

Plan of correction: Executive Director provided proof of new phones being purchased so every staff is able to receive notice of pendant calls. ED agreed to conduct an audit of pendant logs to identify problem areas, and provide in-service training. ED will secure an effective system regarding staff having magnets on their person or nearby at all times to clear resident calls. ED will provided training logs by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a) · Plan of correction due date: Oct 31, 2025

(a) In addition to the rights listed in Section 87468.1...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met, as evidenced by: Based on interviews and records review, Licensee did not ensure resident supervision needs were met. This posed a potential safety risk to 96 of 96 persons in care.the state’s words, verbatim · CDSS document, Oct 1, 2025

Plan of correction: The identified staff who were found to be sleeping on shift were terminated. Executive Director agreed to retrain staff and training supervisors regarding phone use on the floor. Managers will also conduct increased checks on PM and NOC shift.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Health and Wellness Director Ellie Davis, to discuss the purpose of the visit. The purpose of today's visit was to amend a case management report for facility visit conducted on 07/8/2025. No deficiencies were cited or observed on this date. An exit interview was conducted with Health and Wellness Director Ellie Davis, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jul 9, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Resident Care Coordinator Alexis Encinas and Executive Director Rob Daynes, to discuss the purpose of the visit. Today's visit is in response to the Self-reported incident of a staff member’s (S1) mishandling of resident care for (R1) 06/22/2025. The facility suspended the staff pending internal investigation and terminated S1 on 06/30/2025. LPA conducted a wellness check at the facility; no health or safety issues were identified. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Rob Daynes, Executive Director, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. This is an amended report signed by Health Services Director Ellie Davis.the state’s words, verbatim · CDSS document, Jul 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Aug 8, 2025

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This requirement was not met, as evidenced by: based on interviews and records, Licensee did not ensure 1 of 60 residents (R1) was free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, which posed a safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: Licensee immediately suspended the staff member in question and subsequently terminated the staff on 06/30/25. ED will conduct a detailed in-service training regarding resident personal rights, dignity, and abuse. Proof of training will be submitted to the Department by the POC due date. This is an amended report for signature, signed by Health Services Director Ellie Davis.

Allegation investigated: Staff did not treat resident with dignity and respect.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Rob Daynes. On 10/14/2024 it was alleged that Staff did not treat resident with dignity and respect. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, records review, and LPA observations. Staff interviews did not corroborate the allegation, as staff consistently informed not hearing of or witnessing another staff treating a resident without dignity. Staff informed that the resident in question, R1, had become more reclusive and resistant to care due to a change in condition. An outside medical professional familiar with R1's care at the facility informed not observing any dignity issues between staff and R1. (Continued on LIC9099 p.2) Unsubstantiated (Continued from LIC9099 p.1) The outside source corroborated staff statements regarding R1's resistance to care and change in condition. The outside source further informed that R1 had been making emotionally-charged statements about their care that were not really happening, such as insinuating that they do not have a choice in activities of daily living (ADLs), as if they were being forced. The outside source informed that staff had become resourceful in making sure R1's care needs were met and did not have any concerns. During and unannounced facility visit LPA walked the floor in question and only observed the stairwell door to close loudly, which was not near R1's room. LPA observed R1's room door slightly ajar during the visit while R1 was sleeping. LPA did not observe the caregivers on the floor to be loud or deal with any resident in a way that violated their dignity. Interviews were attempted with R1, however R1 was observed to be sleeping during the facility visit and unable to be interviewed. No facility records were found to affirm or refute the allegation. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Rob Daynes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 22, 2025 · control 08-AS-20241014144500

Allegation investigated: Staff did not distribute residents' medications as prescribed. Staff did not ensure that residents' medications were stored in their original container.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Rob Daynes. On 12/16/2024 it was alleged that staff did not distribute residents' medication as prescribed, and staff did not ensure that residents' medications were stored in their original container. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Seven (7) staff were interviewed regarding medication administration, six (6) of whom were Med Techs or trained to pass medications. All staff provided consistent information regarding the process for passing medications. No staff had observed or were aware of medication errors that had occurred. (Continued on LIC9099 p.2) Unsubstantiated (Continued from LIC9099 p.1) Resident interviews did not corroborate the allegation. One resident that was claimed to have been involved in a medication error stated they had no issues at the facility and that the medication administration was good. Attempts were made to interview the second resident noted to have suffered a medication error, but the resident was unable to be interviewed. Facility records were reviewed regarding the allegation. Facility training records for Medication Technicians (Med Techs) were consistent with the medication processes listed by the Med Techs during interview. No records were found to show that a medication error had occurred. Regarding the allegation, "Staff did not ensure that residents' medications are stored in its original container", Staff members consistently stated that they had not observed any staff pre-pour medications. Staff informed that Med Techs actively pour while administering medications, or prepare all medications at once then pass to residents, with the preparation time not exceeding more than 1 hour, per company policy. Staff informed that inconsistencies existed with specific staff regarding the interpretation of what pre-pouring was. The staff member accused of pre-pouring informed that the resident was right in front of them during the medication administration and they were the only resident that was being assisted at the time, there was no confusion with the cups and no pre-pouring occurred. Review of facility records showed substantial medication training consistent with staff statements regarding how medications were administered at the facility. The facility's medication training policy dated December 2023 stated, "Resident medications may only be poured for a single med pass at a time". LPA directly observed the medication procedures and medication carts during two unannounced facility visits. LPA did not observe any medication cups that had been prepared in advance, locked or unlocked, around the facility or in the medication cart drawers. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Rob Daynes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 22, 2025 · control 08-AS-20241216101746

Allegation investigated: Facility door(s) were in disrepair. Resident(s) were not afforded privacy while care was being provided.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Rob Daynes. On 12/16/2024 it was alleged that facility doors were in disrepair and residents were not afforded privacy while care was being provided. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. It was claimed that resident doors at the facility were being propped open and that doors did not close properly. Staff members interviewed consistently informed that no resident doors had been kept open by staff without the resident's consent or outside of their preference. Staff informed that two residents prefered their doors to remain open, and staff checked on them regularly. No staff had knowledge of any resident door being in disrepair. (Continued on LIC9099 p.2) Unsubstantiated (Continued from LIC9099 p.1) Resident interviews did not corroborate the allegation. No resident expressed during interview that doors at the facility were in disrepair. Attempts were made to interview Resident 1 (R1) without success. Resident 2 (R2) was sleeping during LPA's facility visit and was unable to be interviewed. No records were found to refute or affirm the allegation. During unannounced facility visits LPA walked the 1st and 2nd assisted living floors. LPA observed all resident doors closed or open a very small amount. LPA did not observe any doors propped open or any door in disrepair. Regarding the allegation, "Resident(s) were not afforded privacy while care was being provided", it was alleged that staff did not close resident doors while providing incontinence care, resulting in privacy violations. Staff members unanimously stated during interviews that resident doors were closed while residents were being changed. No staff had knowledge of a resident's privacy being violated by having their door propped open while being changed. Resident interviews did not corroborate the allegation. Residents did not express concerns regarding privacy. No records were found to refute or affirm the allegation. During unannounced facility visits LPA walked the 1st and 2nd assisted living floors. LPA observed all resident doors closed or open a very small amount. LPA did not observe any doors to be open while a resident was being assisted with toileting or incontinence care. In common areas LPA observed staff assisting residents to the bathroom to be changed, and observed the restroom doors to be closed. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Rob Daynes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 22, 2025 · control 08-AS-20241216162250

Allegation investigated: Resident fall due to neglect.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Rob Daynes. On 07/02/2024 it was alleged that staff neglect led to Resident 1 (R1)'s fall, resulting in R1 lying on the floor throughout the night. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Staff interviews did not corroborate the allegation, as staff consistently denied that Resident 1 (R1) suffered a fall that resulted in them being unattended for hours without staff help. Staff informed that R1 lived in the Assisted Living section of the building and was mostly independent, not requiring assistance with Activities of Daily Living (ADLs) or checks throughout the night. Staff interviews revealed that R1 began to experience a change in cognition during the timeframe of complaint, experiencing disorientation to time and place, and misremembering events. (Continued on LIC9099 p.2) Unsubstantiated (Continued from LIC9099 p.1) Staff interviews further revealed that R1 slipped from their bed the evening of 06/28/2024 with no injuries, and staff responded to assist them during the event. An outside advocacy agency familiar with the facility and R1's care was contacted and stated they had no concerns regarding the facility's supervision and care to residents. The outside source remarked that R1 may have been experiencing confusion when they made the statement about lying on the ground. A second outside source informed that R1 presented as independent. Records review revealed facility pendant and Narrative Charting logs during the timeframe of complaint. The documents showed that R1 pressed their pendant twice during the early morning on 06/28/24, and was responded to within 7 minutes, and then 2 minutes. The 2-minute response time was noted to be when R1 was found sitting on their bedroom floor after slipping from their bed; R1 informed staff that they did not suffer an injury during this incident. Additional facility and outside source records showed that R1 was evaluated to be independent upon moving into the facility and was able to perform all Activities of Daily Living (ADLs) without assistance, including going for walks outside of the facility unassisted. No records were found to establish that R1 required routine nighttime checks, or that staff delayed in responding to R1's pendant call when they requested help. During an unannounced facility visit LPA interviewed R1. LPA noted that R1 had moved from the Assisted Living section of the building to the Memory Care unit. R1 stated that they did not recall falling and lying on the ground all night without assistance. R1 stated that staff came right away when they pushed their call button and provided great care. R1 informed they loved living at the facility and had no issues with the care provided. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Rob Daynes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 27, 2025 · control 08-AS-20240702125951

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Executive Director Rob Daynes. The facility's license shows a maximum capacity of 100 non-ambulatory residents, 8 (eight) of whom may be bedridden. All rooms approved for bedridden. 3rd and 4th floor approved for delayed egress. Hospice waiver approved for 20. During today’s inspection there were 98 residents in care. LPA and Executive Director Rob Daynes toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Executive Director Rob Daynes, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Rob Daynes to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 27, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Dang Nguyen conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. LPA was greeted by, identified himself to, and explained the purpose of the visit to the applicant’s representative, Robert Daynes. The facility fire clearance was granted on 01/22/2024 and reflected that the facility was approved for one hundred (100) residents in total, of which eight (8) may be bedridden and all may be non-ambulatory. On the date of LPA's site visit, there were eighty-nine (89) residents in care, of which thirty-seven (37) were non-ambulatory and none were bedridden. The submitted facility sketch was consistent with the current layout of the facility. During today’s visit, LPA, accompanied by the applicant’s representative, toured the interior and exterior of the facility and inspected various rooms. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets, sinks, and showers were in working order. The facility’s ambient internal temperature was compliant at 78 degrees F. Hot water temperature at taps accessible to residents were also compliant: 1st Floor Bistro sink was 113.4 F, 1st Floor Lounge sink was 109.4 F, 1st Floor Activity Room sink was 108.3 F, Room #104 sink was 108.4 F, Room #117 sink was 106.3 F; 2nd Floor Therapy Room sink was 107.2 F, Room #203 sink was 109.8 F, Room #223 sink was 107.8 F; 3rd Floor Dining Room sink was 108 F, Room #304 sink was 108.7 F, Room #324 sink was 108.3 F; 4th Floor Dining Room sink was 112.4 F, Room #407 sink was 107.6 F, and Room #423 sink was 111.2 F. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] The facility has enough linens, hygiene supplies, cooking and dining supplies, and perishable and non-perishable food for future resident use. All kitchen appliances were in working order. Appliance temperatures were compliant: Main Kitchen Walk-In Cooler was 37 F, Main Kitchen Salad Cooler was 37 F, 1st Floor Bistro Refrigerator was 29 F, 1st Floor Lounge Refrigerator was 39 F, 1st Floor Activity Room Refrigerator was 38 F, 3rd Floor Dining Room Refrigerators were 38 F and 39 F, and 4th Floor Dining Room Refrigerators were 39 F and 38 F. Main Kitchen Walk-In Freezer was 0 F, Main Kitchen Ice Cream Freezer was 0 F, 1st Floor Lounge Freezer was 0 F, 1st Floor Activity Room Freezer was -8 F, 3rd Floor Dining Room Freezer was 0 F, and 4th Floor Dining Room Freezer was 0 F. The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of sharp objects, medication, and confidential resident and staff records. No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per the applicant’s representative, no firearms or ammunition are or will be stored at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. Fire extinguishers were serviced within the last twelve months. A complete first aid kit was present. Required licensing postings were observed in visible areas of the facility. The items reviewed were complaint with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. The applicant passed the pre-licensing inspection. LPA also provided the Component III Training during today’s visit. Daynes was advised that the facility’s application is pending management final review and approval. An exit interview was conducted with the applicant’s representative, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Feb 29, 2024