Ivy Park at San Ramon

Type of visit: Case Management - Other

On 8/28/2026 at 1:30pm, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a Case Management visit. LPA met with Executive Director Gilbert Castro and explained reason for visit. While LPA A. Gomez was conducting complaint investigation 15-AS-20260825142852 on 8/28/2026 LPA observed the following deficiencies: While making observations of R2's apartment LPA observed open medications in the living room next to a wrist watch (Rosuvastatin, Levothroxine, and Asprin 81MG) R2's physicians report (LIC602) dated 6/18/26 states that they are not able to manage prescription medications, PRN medications, or store medications. LPA observed that the medication administration record (MAR) for R2 shows that the observed meds had been taken from 8/2/2026 to 8/27/2026 and refused on 8/1/2026 however LPA observed un-taken meds in R2s room on 8/28/2026. Staff did not provide the basic service of medication assistance as was agreed upon in R2's appraisal of needs and services (Resident Assessment) dated 1/15/2026. LPA observed scissors on the dining room table and cleaning chemicals under the kitchen sink in R2's apartment. R2's physicians report (LIC602) dated 6/18/26 states that they are at risk and/or other residents are at risk if they have access to these items. report continues on LIC809-C *** Civil penalty assessed for $250 for repeat violation*** R2 was transferred to the hospital at approximately 5pm on 8/27/2026. LPA observed that the medications Rosuvastatin, Levothroxine, and Asprin 81MG are to be taken in the morning according to the MAR. LPA spoke with Health Service Director who states that when med-techs administer medication they should hand it to the resident and ensure that it is taken. In the event that a resident does not take their medication or a resident refuses after it has already been dispensed staff are to return the medications to the med-room to follow disposal procedures. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 28, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Sep 11, 2026

(h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidence by: Based on observation, the licensee did not comply with the section cited above in R2 having centrally stored medications accessible in their apartment which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 28, 2026

Plan of correction: By POC facility agrees to retrain staff members on medication expectations and notify CCLD.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Sep 11, 2026

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidence by: Based on observation, the licensee did not comply with the section cited above in R2 having dangerous items and poisons accessible in their apartment which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 28, 2026

Plan of correction: By POC facility agrees to train all staff on identifying dangerous items and what to do and notify CCLD Civil Penalty Assesed

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Sep 11, 2026

(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, as specified in Section 87608, Postural Supports. This requirement was not met as evidence by: Based on observation, the licensee did not comply with the section cited above in not providing the basic medication assistance and care service as outlined in R2's plan which posed a potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 28, 2026

Plan of correction: By POC facility agrees to conduct a refresher course to all med-techs on administering medications and provide refresher documents to CCLD.

Allegation investigated: Staff mismanage residents' medication Staff are not following reporting requirements Staff are not disposing of residents' medication properly Unqualified staff are managing residents' medications

On 08/11/2026 at 9:30 AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver findings regarding the allegations above. LPA met with Business Office Director Thaleana Jones and explained the purpose of the visit. On 8/5/2026 LPA toured facility including memory care and conducted interviews. LPA obtained staff schedules, training documents, destruction logs for selected residents, and charting notes. report continues on LIC 9099-C Substantiated Pg. 2 On the allegation "Staff mismanage residents' medication " on 8/5/2026 at 10:47AM LPA interviewed the Health Service Director. LPA asked Health Service Director (HSD) to tell them about the med errors in July 2026. HSD stated that the only med error that they remembered happened on a Saturday in July. HSD states that a Health and Wellness nurse in memory care staff 3 (S3) called out so the only person available to pass meds would have been the Memory Care Director however no one passed morning meds. HSD looked backed in the calendar and confirmed that this incident happened 7/11/2026. On 8/5/2025 at 11:26AM LPA interviewed the Memory Care Director (MCD). MCD states that in July there were over 100 medication errors documented in the system labeled as missed meds. MCD states that a majority of the errors occurred on the same day (7/11/2026) due to there not being anyone on the floor to give the meds in memory care. MCD stated that R2's responsible party reported they were getting meds late which prompted the review. States that when the error was found on 7/15/2026 they notified the Executive Director (ED) as well as the Regional Memory Care specialist Rachel David. LPA also obtained copies of the electronic medication administration record E-MAR for all residents in Memory Care for the date 7/11/2026 as well as the missed meds log generated by the E-MAR . LPA observed that on 7/11/2026 7 residents (R1-R7) were listed as missed meds for that date. All other residents E-MAR had been signed off by the HSD as received for the morning medication pass although HSD states that all residents missed their morning medications. Based on interview and record review the allegation "Staff mismanage residents' medication" is substantiated. On the allegation "Staff are not following reporting requirements" On 8/5/2026 LPA conducted interviews and a record review of all unusual incident reports (UIR's).When LPA interviewed MCD they stated that when the medication error was for 7/11/2026 found on 7/15/2026 they notified the ED as well as the Regional Memory Care specialist Rachel David. MCD states that they did not personally notify the residents family (rp's) or CCLD. On 8/5/2026 when LPA interviewed the ED the ED stated they called Licensing on 7/24/2026 to inform them of the med errors that occurred on 7/11/2026 and that they stated that they would be sending out the Unusual Incident reports however they never did. LPA was unable to verify if ED ever called Licensing in regard to the 7/11/2026 med error. ED states that they never notified the family of the med errors or the doctors of the residents. Therefore the allegation "Staff are not following reporting requirements" is substantiated. Report continues on LIC9099-C Pg 3. On the allegation "Staff are not disposing of residents' medication properly" LPA reviewed records, made observations, and conducted interviews. On 8/5/2026 LPA observed in destroy bin among other medications an Abuterol inhaler. The inhaler was confirmed to belong to memory care resident R6. The inhaler was observed with 94 puffs remaining. LPA requested the destroy log for the inhaler as well as the MAR/Centrally Stored to show the prescription. LPA observed that R6 was still prescribed the inhaler and HSD came to the med room to help locate the destroy log. HSD states that there is no record for the inhaler in the destroy log. Therefore the allegation "Staff are not disposing of residents' medication properly" is Substantiated. On the allegation "Unqualified staff are managing residents' medications" LPA conducted interviews and reviewed training records. On 8/5/2026 during an interview with the HSD the HSD stated that Activities assistant S2 has been shadowing medications and on one occasion administered memory care residents medication unsupervised because they had to go to AL (Date not provided). LPA requested training's related to Medication for S2 and HSD states that they do not have any records to provide. Therefore the allegation "Unqualified staff are managing residents' medications" is Substantiated. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided. On the allegation "Staff are not safeguarding residents' private information" While at the facility LPA did not observe any unsecure records or resident information. LPA toured Memory Care as well as Assisted Living. All records observed were secured and locked away prior to review. Therefore the allegation Staff are not safeguarding residents' private information is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report to provided.the state’s words, verbatim · CDSS document, Aug 11, 2026 · control 15-AS-20260804134603

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Aug 18, 2026

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidence by: Based on interview and record review, the licensee did not comply with the section cited above in not having any staff to administer memory care residents morning medications on 7/11/2026 which resulted in medication mismanagment due to all memory care residents missing their morning meds which posed an immedite health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: By POC facility agrees to permanently schedule at least two med-techs per shift (not including members of leadership) for each department and submit schedules to CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(i) · Plan of correction due date: Sep 15, 2026

(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: This requirement was not me as Evidence by: Based on interview and record review, the licensee did not comply with the section cited above in R6's medication having been destroyed and observed mixed in with destroyed medications in the memory care med room destroy bin while not having the required documentation or any documentation recording the destruction which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: By POC Facility agrees to have all med-techs, and all members of the clinical team re-train in Incidental Medical and Dental Care by an approved CCLD vendor not previously used by the licensee of facility and provide training certificates to CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69(a)(1) · Plan of correction due date: Aug 18, 2026

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:(1)In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. This requirement was not me as Evidence by: Based on interview and record review, the licensee did not comply with the section cited above in S2 assisting with the self-administration of medications prior to meeting the above training requirements/ qualifications and having no training record available for review which posed a potential safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: By POC facility agrees to audit all staff who are assisting with the self-administration of medications training records and remove all staff immediately who do not meet the requirements, provide the required training prior to allowing assisting with the self-administration of medications, and notify CCLD of the staff involved/retrained and who provided assistance with the self-administration of medications while other staff was being retrained.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Sep 1, 2026

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidence by Based on interview and record review, the licensee did not comply with the section cited above in not reporting the medication error as of 8/5/2026 that occured for all resident in memory care on 7/11/2026 in the morning to all of the required parties which posed an immedite personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: By POC facility agrees to have all care staff, med techs, and managment team retrain on reporting requirements by a CCLD approved vendor not previously utilized by the facility or licensee and provide all training certificates to CCLD.

Allegation investigated: Facility in disrepair

On 07/28/2026 at 9:30 AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver findings regarding the allegation above. LPA met with Business Office Director Thaleana Jones and Executive Director Gilbert Castro and explained the purpose of the visit. During the course of the investigation LPA spoke with ED who states that the elevator (2) located near main dining has been inoperable since approximately May 21 2026 therefore the allegation is Substanciated. LPA observed that on 7/21/2026 LPA D Doidge delivered substanciated findnings for complaint 15-AS-20260629220357 that the allegations are the same in nature and stem from the same timeframe therefore LPA will not recite for deficiencies. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. No On the allegation Staff did not provide adequate food accommodations to residents in care LPA observed the Lunch delivery service on 7/29/2026. LPA observed 5 meals delivered on the 3rd floor to Resident- R2, R3, R4, R5, R6. One tray was delivered to the second floor to R7. LPA felt the temperature of each meal delivered on the third floor and observed R2's meal was noticeably cold while all other meals delivered were either warm or hot. LPA observed that R2, R3, R4, R6, and R7 ordered the daily special which was tamales. R5 ordered a grilled cheese and soup. LPA also briefly spoke with R2-R7. R2, R6, and R7 each stated that their meals are typically delivered cold and have to be reheated upon LPA asking how the temperature of their meals are usually delivered. R3, R4, and R5 all stated that their meals temperature are usually fine when asked the same question. LPA also observed each residents meal ticket order an observed that the average time between the order being made and delivery of the tray to the rooms was approximately 10 minutes. LPA also spoke with the ED who states that there have been a few occasions where residents have complained of cold meals and that when that happens they send them a new tray. LPA observed that all residents rooms are equipped with microwaves for reheating food. Based on all observations made, regulatory expectations, and interviews the above allegation is Unsubstantiated. * LPA did advise ED to prioritize meal tray services to ensure residents meals are delivered timely, fresh, and hot Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 15-AS-20260609132011

Allegation investigated: Staff does not ensure facility elevator is in good repair.

On 07/21/2026 at 2:30 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to deliver findings regarding the allegation above. LPA met with Business Office Director Thaleana Jones and Executive Director Gilbert Castro and explained the purpose of the visit. During the course of the investigation toured the facility, inspected the elevators. LPA interviewed S1, S2, S3, S4 and S5 as well as R1, R2, R3 and W1. LPA reviewed and obtained copies of R1, R2, and R3’s Physician’s Report, Admission Agreements, correspondence between the facility and residents, and correspondence between the facility and the repair company for the elevator (Otis) regarding the elevator Allegations: Staff does not ensure facility elevator is in good repair. Continued on LIC9099-C Substantiated Continued from lIC9099 Investigation Findings: It was reported to the department that a resident cannot regularly attend dining services due to an elevator being out of service. The resident also reports that when meal delivery is requested, the meals are often not delivered. As a result, the resident has gone without meals paid for. R1 and R2 stated that they prefer to get meals delivered instead of using another elevator farther from their room. R1 does not require assistance with feeding and uses the free meal service provided by the facility instead of going to the dining room as a preference. R1 has not been restricted from ordering food or going to the dining room on R1’s own. R2 uses the meal service as R2 prefers to eat alone in R2’s room. R3 informed LPA that R3 prefers to eat in the dining room and uses the stairs. S1 and S2 informed LPA that due to an elevator being temporarily out of service, the facility is offering residents on the third floor affected by the elevator being out of service a meal delivery service. Residents can either call down to the front desk or send a ticket to the kitchen to place an order. Caregivers on the third floor then pick up and deliver the orders. LPA reviewed files for four residents on the affected floor, none require assistance with meals or feeding. LPA observed dinning room to be fully functioning, staffed, and accessible to all residents. Based on interviews conducted and file review, the above allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided. Continued from LIC9099 Investigation Findings: It was reported to the department that the primary elevator serving a resident’s apartment has been out of service for longer than eight weeks. Based on observation and interviews with staff and residents, the main elevator (Elevator two) has been out of service since May 21st. Despite efforts made by management to get the elevator repaired, it remains nonoperational, therefore the allegation above is SUBSTANTIATED. The preponderance of evidence is met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 809-D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in a civil penalty. Deficiency plan and proof of correction were discussed with Executive Director Gilbert Castro. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Jul 21, 2026 · control 15-AS-20260629220357

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 4, 2026

Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidence by: Based on observation and record review, licensee did not comply with the section cited above by having the main elevator (Elevator two) in disrepair which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Jul 21, 2026

Plan of correction: Executive Director (ED) has agreed to obtain a written detail plan on the repair process with a clearer estimated time of repair with completion dates for each step of the process. ED will submit the plan to CCLD by POC date.

Allegation investigated: Lack of supervision resulting in resident being sexually abused at the facility. Facility not following reporting requirements

On 3/24/2026 at 10:40 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver findings for the above allegations. LPA met with Executive Director, Gilbert Castro and explained the purpose of the visit. During course of the investigation, LPA A Gomez conducted interviews with facility staff, and complainant. Documents including but not limited to: Residents Admission agreements, physician’s reports, care plans, and care notes were reviewed Report Continues on LIC 9099-C Unsubstantiated PG 2 On the allegation, lack of supervision, resulting in resident being sexually abused at the facility LPA conducted interviews, reviewed R1 and R2’s care plan, R1 and R2’s physicians report, and care notes. LPA observed that R1 and R2 were both memory care residents with a diagnosis of dementia. On 8/13/2025 it is alleged that R2 entered R1’s room and sexually assaulted them. LPA interviewed S1 who is the lead for S3 who stated that on 8/13/2025 S3 had led R2 to Dining for breakfast. Approximately 30 minutes later, S3 noticed that R2 was not at dining. S1 states that other facility staff and S3 were still getting residents to dining for breakfast at this time. R2 was discovered in R1’s room during this time. S1 states that they were told that it appeared that R1 and R2 may have engaged in sexual activities. LPA conducted interviews with S2 S4 and S5. All staff stated that they had heard about the interaction between R1 and R2 however, residents have a personal right to engage in sexual activity, unless there is a court appointed conservator. LPA found that R1 and R2 are not conserved. LPA attempted to interview R1 but was unable to due to their dementia diagnosis. R2 was also unavailable to interview. LPA made attempts to contact S3 but was unable to interview S3 as they are not permanent staff. LPA was unable to determine if the interaction between R1 and R2 was consensual therefore, the allegation of lack of supervision resulting in resident being sexually abused at the facility is unsubstantiated. Report Continues on LIC 9099-C PG. 3 On the allegation facility not following reporting requirements LPA reviewed records and unusual incident reports. LPA observed that the facility reported the interaction between R1 and R2 on 8/18/2025 which is within title 22 guidelines of reporting requirements. LPA observed that the incident happened on 8/13/2025 was reported to police, responsible parties, and to licensing therefore the allegation facility not following reporting requirements is unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 24, 2026 · control 15-AS-20250820161102

Allegation investigated: Facility staff neglected resident contributing to questionable death

On 3/24/2026 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver findings for the above allegation. LPA met with Executive Director, Gilbert Castro and explained the purpose of the visit. During course of the investigation, the Department obtained documents including but not limited to: R1’s admission agreement, physician’s report, care plan, medication log, incident reports, discharge notes, death certificate, and medical records. Report continues on LIC9099-C Unsubstantiated PG. 2 On the allegation “Facility staff neglected resident contributing to questionable death” the following was found. R1 was admitted to the facility on 4/29/2024. On 8/8/24, the facility staff took over medication administration for R1 per their responsible parties request. On 8/27/24, R1 was having chest pains and was sent to San Ramon Valley Regional Hospital. R1 was diagnosed with low potassium. R1 was treated and sent back to the facility the same day with no new orders. On 9/11/24, R1 was having trouble breathing and was sent to the hospital on 9/12/24. R1 was diagnosed with low potassium levels and bloody fluid coming from the lungs. R1 was discharged from the hospital on 9/26/24. R1 did not return to the facility and was transferred to home health care at their responsible parties home. On 9/28/24, R1 was having shortness of breath and weakness and was transported back to the hospital while in their families care. On 10/4/24, R1 was transferred to a skilled nursing facility (SNF). On 11 /7/24, R1 was having trouble breathing while at the SNF. R1’s lungs were drained and appeared to be doing better. On 11/12/24, R1 tested positive for MRSA and went back to the hospital. R1 was placed on hospice and passed at the hospital on 11/17/24. It was alleged that Ivy Park San Ramon missed R1’s potassium medication however it could not be confirmed after a review of the Medication Administration Record (MAR ) For 7/01/2024-9/26/2024. R1 was also taking medication for congestive heart failure, medications were classified as a diuretic (water pill), a common side effect is a drop in potassium level (hypokalemia). According to Mayo clinic hypokalemia is, “Low potassium a condition in which the potassium level in your bloodstream is lower than is typical. The medical term for this condition is hypokalemia”. Report continues on LIC9099-C PG. 3 R1 also had a complex past medical history with comorbidities and was taking multiple medications as prescribed. A copy of R1’s death certificate revealed R1 passed away on 11/17/2024 at JOHN MUIR MEDICAL CENTER-WALNUT CREEK and the cause of death was listed as chronic respiratory failure and heart failure; the etiology is unknown. A causal connection could not be established between the care at the facility and R1s expiration. Therefore, the allegation “Facility staff neglected resident contributing to questionable death” is Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 24, 2026 · control 15-AS-20250603102000

Type of visit: Case Management - Annual Continuation

On 3/24/2026 at 11:30 AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct the Annual Continuation Inspection to complete the Annual Required Inspection that began on 3/6/2026. LPA met with Executive Director, Gilbert Castro and explained the purpose of the visit. On 3/24/2026 LPA reviewed 6 resident records and 5 staff records. 5 of 5 associated to the facility. Emergency Disaster Plan was last reviewed on 3/13/2026. Emergency disaster drill was last conducted on 3/8/2026. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT 3/6/26: Downstairs common bathroom emergency call button not notifying caregivers pagers- disrepair *** Dangerous Items identified: gardening sheers unlocked in activities room under sink, chemicals unlocked under sink/ butane, room 196 memory care (mc) hot tools, room 297 mc unlocked cleaning supplies/chemical hot tools. Not enough staffing memory care; observed residents left unattended in activities room (2 caregivers on the floor for 30 residents. 1 upstairs 1 down), staff were also unaware that MC has emergency call buttons. Room 293 Incontinence not properly disposed creating an Odor (thrown in open waste basket by bed) Hot water measured at 129.2 degrees F room 269 *** R3, R4, R5,and R6 appraisals of needs and services not up to date ***Civil Penalties assessed for repeat violations in 12 months $250 X 2*** Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 3/31/2026: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 24, 2026

The state marks this report as 10 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 3/24/2026 at 10:50 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a Case Management visit. LPA met with Executive Director, Gilbert Castro and explained the purpose of the visit. While LPA A Gomez was conducting a complaint investigation (15-AS-20250820161102) LPA found through interviews an incident reports that facility is not providing adequate care and supervision. LPA found that on 8/13/2025 R2 entered R1’s room without staff knowing during mealtime due to staff not monitoring residents being brought down to dining. LPA interviewed staff (S1) who stated that at the time of the incident “there was not a system in place to ensure the monitoring of residents being brought down to dining and that it was common for residents to wander off.” R1 and R2 were both memory care residents. The deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Mar 24, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 24, 2026

(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidence by: Based on interviews the licensee did not comply with the section cited above by not having adequete staffing in memory care which allowed R2 to wander into R1's room unbeknownst to staff which posed a potential personal rights violation to residents in carethe state’s words, verbatim · CDSS document, Mar 24, 2026

Plan of correction: Facility has hired additional staff and trained them POC clear.

Type of visit: Required - 1 Year

On 3/6/26 at 1:00PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director (ED), Gilbert Castro and explained the purpose of the visit. The facility’s fire clearance was approved for 162 residents of which 119 may be non-ambulatory and 4 bedridden. LPA toured the facility with ED including but not limited to residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 69 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 129.2, 111.9, 111.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid flooring/strips. Freezer measured at 0 degrees and refrigerator measured at 40 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Fire extinguisher was last serviced on 5/30/2025. No deficiencies cited at this time. LPA will return at a later date to continue annual inspection, records review, and cite for deficiencies observed. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 6, 2026

Allegation investigated: Staff did not give resident's responsible party proper notification of resident's room change.

On 11/19/2025 at 1:20 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver investigation findings. LPA met with Business Office Director, Thaleana Jones and explained the purpose of the visit. During the course of the investigation LPA obtained copies of current resident roster, List of residents who moved rooms in last 60 days, notifications of the moves, responsible persons information, POA/Conservator information if available. Report continues on LIC9099-C Substantiated LPA also received an email correspondence from Executive Director who stated that they were "under the impression that our Health Service Director confirmed the date of Oct 29, 2025 with the responsible party (RP). Turns out that was not the case." regarding R1 being moved rooms. It was explained to LPA by Business Office Director that the family was aware that R1 was going to move rooms however the facility never confirmed the date of the move and did not provide a written 30 day notice to the responsible party therefore the allegation "Staff did not give resident's responsible party proper notification of resident's room change" is substantiated. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 15-AS-20251031115921

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(16) · Plan of correction due date: Nov 19, 2025

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(16)To written notice of any room changes at least 30 days in advance unless a room change is agreed to by the resident, required to fill a vacant bed, or necessary due to an emergency. This requirement was not met as evidence by: Based on record review and interview R1 did not receive a written 30 day notice of room change prior to the change which poses a potential personal rights risk to resident in carethe state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: Facility has implemented a new system of documenting and notifing residents and their responsible parties of room changes and provided the new form to CCLD. POC clear

Allegation investigated: Staff are not safeguarding residents' medications Staff did not administer resident's medications as prescribed

On 9/26/2025 at 9:30 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to deliver findings regarding the allegations above. LPA met with the Business Office Director, Jones Thaleana. Executive Director (ED) Gilbert Castro informed them of the reason for the visit. ED was not available during the time and gave verbal permission to the Business Office Director to sign the report . It was alleged that Staff are not safeguarding residents' medications- Substantiated During the investigation, LPA conducted interviews and reviewed files. LPA reviews the photo, which shows R1 medication was left on the table on Aug 23. 2023 at 11:24 am. LPA reviewed the R1 Physician report, which indicates that R1 is unable to manage their own medication. On Aug 31. 2023 LPA interviewed staff and attempted to interview residents. S4 stated that S4 did not remember going back to the R1 room to pick up the medication left on the dresser. S1 stated that there’s a one-hour gap that MED-Tech can go back to retrieve the medication or witness residents take the medication. S3 admitted that S4 forgot to pick up the medication in the R1 room. Report continues on LIC 9099-C Substantiated It was alleged that the Staff did not administer the resident's medications as prescribed- Substantiated During the course of investigation, LPA interviewed staff, record review, and other evidence gathered during the investigation, the allegation that staff did not administer the resident’s medications as prescribed was found to be substantiated. Records indicate that staff failed to follow the physician’s orders regarding medication administration, resulting in missed and/or delayed doses. This practice poses a potential health and safety risk to residents in care. The following deficiencies were observed see LIC 809D and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. An exit interview was conducted, and a copy of this report and appeal rights is provided.the state’s words, verbatim · CDSS document, Sep 26, 2025 · control 15-AS-20230824130321

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87465(h)(2) · Plan of correction due date: Oct 10, 2025

87465(h)(2) Incidental Medical and Dental Care “Once ordered by the physician, medications shall be given according to the physician’s directions.” Residents’ medications must be safeguarded to ensure they are administered only to the prescribed individual and strictly in accordance with the physician’s directions. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not ensure the safeguarding of residents’ medications. Medications were found unsecured and accessible, creating a risk that residents may receive medications not prescribed to them or that doses may not be administered as directed. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 26, 2025

Plan of correction: The licensee shall immediately implement corrective measures to ensure all medications are stored securely and accessible only to trained staff. The licensee shall retrain staff on medication safeguarding policies and procedures. Documentation of staff training and photographs of corrected storage practices shall be submitted to Community Care Licensing by 10/10/2025.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87468.2(a)(4) · Plan of correction due date: Oct 10, 2025

87468.2(a)(4) – Personal Rights of Residents in All Residential Care Facilities for the Elderly “To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.” Residents shall be provided with safe, healthful, and comfortable accommodations, which includes the proper administration of prescribed medications to ensure resident health and safety. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not ensure that medications were administered as prescribed. Documentation confirmed that staff failed to follow physician’s orders regarding medication administration, resulting in missed and/or delayed doses. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 26, 2025

Plan of correction: The licensee shall provide immediate retraining for all staff responsible for medication administration, with emphasis on adherence to physician’s orders and proper medication administration procedures. Proof of completed staff training, including attendance records and training materials, shall be submitted to Community Care Licensing by 10/10/2025.

Allegation investigated: Staff did not provide assistance to resident in a timely manner. Facility is in disrepair.

On 9/16/2025 starting at 9:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver findings. LPA met with Regional OPs Specialist (ROS), Jessica Pryor and explained the purpose of the visit. During the course of the investigation LPA reviewed files, tested quipment, and made observations. On the allegations Staff did not provide assistance to resident in a timely manner and Facility is in disrepair the following was found: Report Continues on LIC9099-C Substantiated On 8/1/2025 LPA conducted tests on residents call button. LPA found that R1's pendant was not working properly and that staff were not notified when it was pressed therefore they were not able to meet the residents need in a timely manner. LPA asked staff when they came to help R1 get ready for meal time if they received a notification for R1's pendent being pressed and they stated "no". During the observation Health and Wellness Director was present. Therefore the allegations are substantiated. ***LPA assessed a civil penalty for repeat violation ($250)*** Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided. On 9/12/2025 LPA reviewed ledgers for a sample of residents. LPA observed that there was a substantial credit for R1. LPA spoke with BOD and ROS regarding the credit to see if they were connected to the allegation of "Staff charged resident for services not rendered". LPA found that the credit was because the resident was overcharged due to an accounting error. LPA reviewed R1's careplans from 2023-present and found that the level of care has not changed. LPA however did observe on one of the careplans that a special code was not inputted correctly which triggered the extra charges. On 8/1/2025 LPA visited with R1, R2, R3 and R4. LPA observed that R1 was refusing care as outlined in their careplan. R2, R3, and R4 did not note any concerns with the level of care that they were being provided and LPA did not observe any concerns. LPA was unable to interview R1 however R2, R3 and R4 all expressed satisfaction with the staff and did not express any concern with staff speaking to them inappropriately. On 9/12/2025 LPA spoke with BOA who stated that there was a concern with an interaction between S1 and R5 however it was found that it did not indicate S1 speaking inappropriately to R5. Therefore the above allegations are unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 16, 2025 · control 15-AS-20250729114132

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Sep 23, 2025

(d) The following shall apply... to all facilities:(2)The premises shall be maintained in a state of good repair... This requirment was not met as evidence by: Based on observations and interview the facility did not comply with the following by R1's call button being in disrepair which poses a potential safety and personal rights violation to residents in carethe state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: By POC facility agrees to inspect and replace residents personal call buttons as neccessary and notify CCLD

Type of visit: Case Management - Health Checks

On 8/21/2025 at 3:45 PM, Licensing Program Analysts (LPAs) A. Gomez and Y Brown conducted a Health & Safety inspection as a result of a priority 1 complaint. LPAs met with Executive Director, Oriesha Morgan and explained the purpose of the visit. LPAs toured facility including but not limited to random apartments, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 126.1 degrees F in room 259. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility orders food supplies on a weekly basis. Refrigerator temperature was observed at 39 degrees F. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 12/8/24. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. **A civil penalty was assessed on todays date for $250 for repeat violations** The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 21, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Aug 25, 2025

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above inhot water temprature measuring at 126.1 which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 21, 2025

Plan of correction: By POC facility agrees to adjust the water to regulations and notify CCLD.

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

On 8/4/2025 at 8:30AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver amended findings in regard to the allegations above. LPA met with Executive Director (ED), Oreisha Morgan and informed them of the reason for the visit. During the investigation, LPA conducted interviews, toured facility, and reviewed files. LPA conducted interviews. On 4/23/2025 LPA interviewed S1 and S2. Report continues on LIC 9099-C Substantiated On 4/23/2025 LPA reviewed files and interviewed S1 and S2 and found the following: LPA observed that there were multiple instances on R1 MAR where medication was marked as administered however R1 was out of the community and unable to have taken the medicine. LPA identified that S1 made the error and found the following in the interview. S1 states that they pre pour medication based on the med list and then hand them out. After hand out they get marked off. S1 states it might have just been a mistake that medication was marked as given when it had not been administered. LPA then spoke with S2 to understand more about how a medication error like this could occur. S2 stated that the system where med-techs have to mark the medications given needs to be pressed twice to reflect not administered or else the system will mark as medication given. They believe that the medication being marked as given was an oversight. LPA already cited for 87465(a) on complaint: 15-AS-20241203085000 The following deficiencies were observed (see LIC 809D on complaint 15-AS-20241203085000) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted and a copy of this report provided. During the course of the investigation LPA interviewed W1 and reviewed correspondences with R1's responsible party. LPA was unable to identify where the facility refused to accept R1 back into care after R1 was sent out to the hospital. LPA also observed that R1's responsible party requested R1's the medication list on 8/28/2024 at 08:21:13 PM PDT via email and that the facility's Health and wellness director (HWD) at the time provided the medication list on 8/28/2024 at 9:30 PM. R1's power of attorney also requested R1's full record and provided proof of POA on 1/22/2025. The initial request was made on or around 1/14/2025 however the proof of POA documents still needed to be submitted based on the correspondences provided. At the time of the request R1 was not a resident of the facility and had passed away. R1 left Ivy park in September of 2024 and passed away a couple of moths later at an unrelated facility. The facility provided the requested records to R1's POA on 1/22/2025 via email as requested by the POA. Therefore the allegations of "Staff refused to accept resident back to the facility" and "Staff did not allow resident's representative to access resident's records" are Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 4, 2025 · control 15-AS-20250310140445

Type of visit: Case Management - Incident

On 8/1/25 at 10:00 AM, Licensing Program Analyst (LPA) A. Gomez conducted a case management visit as a result of an self-reported incident report received 7/24/2025. LPA met with Business Office Director Thaleana Jones and explained the purpose of the visit. It was reported that R1 alleged that R2 hurt them on 7/23/2025. Facility also self-submitted the required SOC341 report of abuse. LPA reviewed R1 physician report and observed that R1 has a diagnosis dementia. R1 and R2 share a room. It was observed that R2 is non-ambulatory and would not have been able to commit what was alleged, there also was no evidence of the allegations. The police and responsible party were also notified. R1 and R2 continue to live together by choice. R1 is being monitored for this change in condition and their needs and services plan has also been updated. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 1, 2025

Type of visit: Case Management - Incident

On 7/1/25 at 3:15 PM, Licensing Program Analyst (LPA) A. Gomez conducted a case management visit as a result of an elopement that occurred on 6/25/2025. LPA met with Executive Director Oreisha Morgan and explained the purpose of the visit. While at the facility on an unrelated incident LPA was made aware that R1 had eloped from the facility on 6/25/2025. Facility faxed incident report for elopement on 7/1/2025 at 5:56AM. R1 is a memory care resident. All egress doors were operational at the time of elopement and it is suspected that R1 exited memory care into assisted living when an unknown staff member departed memory care. R1 was observed in the parking lot by a S1 when arriving to work around 10:10PM. R1 was last observed in their room at approximately 9:40PM. R1 was found without injury and assessed. R1's care plan has since been updated and staff were provided an in service. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: Facility did not prevent R1 from eloping Facility did not report incident in required 24 hour time frame The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 1, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 2, 2025

(a) In addition...the elderly shall have all of the following personal rights:(4) To care, supervision... that meet their individual needs ... This requirement was not met as evidence by: Based on interviews the facility did not meet the requirement above staff neglecting to ensure that the memory care door fully closed behind them which led to R1s elopement which posed an immediate safety risk to residents in carethe state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: Facility updated R1's care plan and provided training to staff POC clear.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(6)(B) · Plan of correction due date: Jul 9, 2025

(6) For each incident of elopement..(B)The licensing agency...no later than the next working day ... This requirment is not met as evidence by: Based on interviews the facility did not meet the requirement above by not reporting the elopement of R1 within 24hrs to CCLD which poses a potential safety risk to residents in carethe state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: By POC facility agrees to review the regulations and provide an in service to staff and notify CCLD.

Type of visit: Case Management - Other

On 7/1/25 at 2:40 PM, Licensing Program Analyst (LPA) A. Gomez conducted a case management visit as a result of delivering an amended complaint. LPA met with Executive Director Orisha Morgan and explained the purpose of the visit. LPA delivered an amended report for complaint #15-AS-20241203085000. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 1, 2025

Type of visit: Case Management - Health Checks

On 6/4/25 at 5:00 PM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Business Director Thaleana Jones and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. A sample of the hot water temperature was measured at 119.6, 119.6, and 114.9 degrees F. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility orders food supplies on a weekly basis. Refrigerator temperature was observed at 40 degrees F. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 5/30/25. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 4, 2025

Allegation investigated: Staff mismanaged residents’ medications. Facility staff failed to notify resident and responsible party Staff did not respond to resident's call button in a timely manner

On 5/29/2025 at 9:20AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver findings in regard to the allegations above. LPA met with Executive Director (ED), Oreisha Morgan and informed them of the reason for the visit. During the investigation, LPA conducted interviews, toured facility, and reviewed files. On 12/09/2024 LPA reviewed interviewed ED. On 4/23/2025 LPA interviewed S1 and S2. LPA also interviewed R2, R3, and R4. Report continues on LIC 9099-C Substantiated On the allegations Staff mismanaged residents’ medications, Facility staff failed to notify resident and responsible party, Staff did not respond to resident's call button in a timely manner the following was found: On 4/23/2025 LPA reviewed files and interviewed S1 and S2 and found the following: LPA observed that there were multiple instances on R2 MAR where medication was marked as administered however R2 was out of the community and unable to have taken the medicine. LPA identified that S1 made the error and found the following in the interview. S1 states that they pre pour medication based on the med list and then hand them out. After hand out they get marked off. S1 states it might have just been a mistake that medication was marked as given when it had not been administered. LPA then spoke with S2 to understand more about how a medication error like this could occur. S2 stated that the system where med-techs have to mark the medications given needs to be pressed twice to reflect not administered or else the system will mark as medication given. They believe that the medication being marked as given was an oversight. On 5/14/2025 LPA also tested the call buttons in memory care and found that the systems to notify staff of calls are not properly working. Memory care coordinator states that they are actively working towards a solution and are currently training staff on how to ensure residents safety without call buttons.On 5/29/2025 LPA tested the call buttons in the room which was occupied by R1. LPA found during the test that the call button in the bathroom was not operational. The ED was not aware that the call button did not work and did not have a work order for it to be serviced. On 12/09/2024 LPA reviewed interviewed ED. ED states that the prior Health and Wellness Director (HWD) would change the residents needs and services and that they would receive the care but that the families were not aware of the cost associated with the care. The ED states that because of the discrepancy they have reimbursed credits. ED states that HWD resigned when confronted with the discrepancy. It was also found before the HWD resigned that reports were not being reported as required. ED states that there were instances where residents care plan did not match the care they needed or did not require. Report continues on LIC9099-C Pg 3 Based on interviews, record reviews, and observations the allegations Facility is in disrepair, Staff are not following the residents care plan, Facility does not send incident reports as required, and Staff are not providing medication as prescribed is SUBSTANTIATED. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 29, 2025 · control 15-AS-20250124161752

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: May 29, 2025

(a) Each licensee shall furnish ... reports...but not limited to, the following: this requirement was not met as evidence by: Based on interview the facility did not comply with the following by not reporting incidents as required which poses a potential safety and personal rights violation to residents in carethe state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: ED states that previous HWD has resigned and new staff has been adequately trained on procedure

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Jun 5, 2025

(d) The following shall apply... to all facilities:(2)The premises shall be maintained in a state of good repair... Based on observations and interview the facility did not comply with the following by the call buttons being in disrepair which poses a potential safety and personal rights violation to residents in carethe state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: By POC ED agrees to have an order for replacment of call buttons that are in disrepair along with their notification counterparts. LPA will return to inspect the call buttons when relaced

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a) · Plan of correction due date: May 29, 2025

(a) A plan ...by compliance with the following: this requirement was not met as evidence by: Based on record review the facility did not comply with the following by having an inaccurate MAR which put into question the validity of the entries which poses a potential safety and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: System has been updated and staff was retrained on how to adequetly document medications.

Allegation investigated: Staff do not ensure a resident has hot water

On 5/29/2025 at 9:00PM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver findings in regard to the allegations above. LPA met with Executive Director (ED), Oreisha Morgan and informed them of the reason for the visit. During the investigation, LPA conducted interviews, toured facility, and reviewed files. On 5/29/2025 LPA spoke with ED and R1. LPA also obtained copies of R1's addmissions agreement Report continues on LIC 9099-C Substantiated On the allegation Staff do not ensure a resident has hot water LPA found the following: When LPA spoke with the ED they states that they were aware that there was an issue with the hot water especially in R1's room. ED states that the issue took a few months to resolve because they were trying to locate the issue and that they resorted to replacing the boiler system for the facility. LA also interviewed R1 who stated that they did not have hot water in 1 of their bathroom showers for a few months. R1 states that their apartment has 2 bathrooms so they were able to get hot water in the other bathroom. R1 states that the hot water has since been restored and they are no longer experiencing any issues. Based on interviews the above allegation is Substantiated. Based on LPAs interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted and a copy of this report providedthe state’s words, verbatim · CDSS document, May 29, 2025 · control 15-AS-20250210111152

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: May 29, 2025

(e) Water supplies and plumbing fixtures shall be maintained as follows:(2)Faucets...Hot water temperatur ... not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).... This requirement was not met as evidence by: Based on interview the facility did not comply with the following by not having hot water in 1 of 2 of R1's showers which poses an immediate safety and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: Facility has obtained a new boiler system and the hot water issue has been resolved.

Allegation investigated: Facility is in disrepair Staff are not following the residents care plan Facility does not send incident reports as required Staff are not providing medication as prescribed

***THIS IS AN AMENDED REPORT*** On 7/1/2025 at 2:40PM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver amended findings in regard to the allegations above. LPA met with Executive Director (ED), Oreisha Morgan and informed them of the reason for the visit. During the investigation, LPA conducted interviews, toured facility, and reviewed files. On 12/09/2024 LPA reviewed interviewed ED. On 4/23/2025 LPA interviewed S1 and S2. LPA also obtained corespondences regarding varios residents. Report continues on LIC 9099-C Substantiated On the allegations Facility is in disrepair, Staff are not following the residents care plan Facility does not send incident reports as required, and Staff are not providing medication as prescribed the following was found. On 12/09/2024 When ED was interviewed the LPA found the following. ED states that when they came in they felt like the facility was not lacking in sanitation and cleanliness in their opinion. However ED did acknowledge that prior to their on boarding the center elevator was down for about a month and a half. The ED states that they just discovered that one of the fireplaces is not operational last week when putting up Christmas decorations. ED states that they are aware of the dryers and washers being out of service but they are not aware of how long they have been out of service. ED stated that they are actively trying to get new carpets but will not know if it is approved by upper management. ED states that the prior Health and Wellness Director (HWD) would change the residents needs and services and that they would receive the care but that the families were not aware of the cost associated with the care. The ED states that because of the discrepancy they have reimbursed credits. ED states that HWD resigned when confronted with the discrepancy. It was also found before the HWD resigned that reports were not being reported as required. ED states that there were instances where residents care plan did not match the care they needed or did not require. On 4/23/2025 LPA reviewed files and interviewed S1 and S2 and found the following: LPA observed that there were multiple instances on R1 MAR where medication was marked as administered however R1 was out of the community and unable to have taken the medicine. LPA identified that S1 made the error and found the following in the interview. S1 states that they pre pour medication based on the med list and then hand them out. After hand out they get marked off. S1 states it might have just been a mistake that medication was marked as given when it had not been administered. LPA then spoke with S2 to understand more about how a medication error like this could occur. S2 stated that the system where med-techs have to mark the medications given needs to be pressed twice to reflect not administered or else the system will mark as medication given. They believe that the medication being marked as given was an oversight. Report continues on LIC9099-C On 5/14/2025 LPA also tested the call buttons in memory care and found that the systems to notify staff of calls are not properly working. Memory care coordinator states that they are actively working towards a solution and are currently training staff on how to ensure residents safety without call buttons. Throughout all visits the LPA also observed that the communities carpet is in disrepair with rips throughout the community. The carpet observed in disrepair is only located throughout the assisted living side of the community. Based on interviews, record reviews, and observations the allegations Facility is in disrepair, Staff are not following the residents care plan, Facility does not send incident reports as required, and Staff are not providing medication as prescribed is SUBSTANTIATED. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. On the allegations The facility is not clean and sanitary, The facility does not provide adequate care for its residents, Facility has insufficient staff to provide adequate care for residents, Facility staff are administering controlled substance inappropriately the following was found: LPA visited the facility on multiple occasions and observed it to be clean and sanitary. LPA also interviews ED who corroborated the cleanliness of the facility. During all visits LPA observed adequate staffing and observed enough staff had been scheduled ED also stated that they have been actively hiring additional staff. LPA interviewed R2, R3, and R4 who all stated that they were happy with the facility and the level of care being provided. Due to the reporting party not providing additional information in relation to the complaint allegations LPA was unable to speak with specific residents relating to the allegations and had to do a random selection of residents therefore the allegations The facility is not clean and sanitary, The facility does not provide adequate care for its residents, Facility has insufficient staff to provide adequate care for residents, Facility staff are administering controlled substance inappropriately is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 14, 2025 · control 15-AS-20241203085000

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: May 21, 2025

(d) The following shall apply... to all facilities:(2)The premises shall be maintained in a state of good repair... Based on observations and interview the facility did not comply with the following by the elevator, fireplace, and other utilities being in disrepair which poses a potential safety and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, May 14, 2025

Plan of correction: Elavator, fireplace, and washing utilities have been repaired or replaced. ED is currently developing a solution for replacment of call buttons that are in disrepair along with their notification counterparts. By POC ED agrees to have an order for all carpets to be replaced in assisted living and send a copy of the work order to ccld. LPA will return to inspect when new carpets are installed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: May 14, 2025

(a) Each licensee shall furnish ... reports...but not limited to, the following: this requirement was not met as evidence by: Based on interview the facility did not comply with the following by not reporting incidents as required which poses a potential safety and personal rights violation to residents in carethe state’s words, verbatim · CDSS document, May 14, 2025

Plan of correction: ED states that previous HWD has resigned and new staff has been adequately trained on procedure

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

(a) A plan ...by compliance with the following: this requirement was not met as evidence by: Based on record review the facility did not comply with the following by having an inaccurate MAR which put into question the validity of the entries which poses a potential safety and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, May 14, 2025

Plan of correction: By POC facility agrees to review the regulation and notify CCLD

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(f) · Plan of correction due date: May 14, 2025

(f) The licensee shall .., communicate ... any significant change ...Documentation...shall be added to the resident’s record. this requirement was not met as evidence by: Based on record review and interview the facility did not comply with the following by previous HWD updating residents care plan and not notifying the appropriate parties and not providing the care specified which poses a potential personal rights violation to residents in care.the state’s words, verbatim · CDSS document, May 14, 2025

Plan of correction: HWD has since resigned and new staff has been trained appropriately.

Type of visit: Required - 1 Year

On 2/20/25 at 10:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Business Office Director, Thaleana Jones and explained the purpose of the visit. The facility’s fire clearance was approved for 162 residents of which 119 may be non-ambulatory and 4 bedridden. LPA toured the facility with maintenance director including but not limited to 5 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 105.8, 133.6, and 107.4 degrees Fahrenheit. Freezer measured at 0 degrees and refrigerator measured at 35 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Fire extinguisher was last serviced on 12/08/2024. Emergency Disaster Plan was last posted on 03/18/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 2/18/2025. At 11:30am, LPA reviewed 5 residents records. At 10:30 am, LPA reviewed 6 staff records and 0 of 6 have current first aid training and associated to the facility. At 2:30pm, LPA reviewed a sample of resident’s medications. Report continues 809-D THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: LPA observed that no staff reviewed files have first Aid LPA observed the water in room 227 at 133.6 degrees F The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 20, 2025

Allegation investigated: Staff did not accord resident's privacy while in care Staff stole items from residents in care

On 1/13/2025 at 9:20AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver findings in regard to the allegations above. LPA met with Executive Director (ED), Oreisha Morgan and informed them of the reason for the visit. During the investigation, LPA conducted interviews, obtained phone call recordings, and reviewed files. On 10/16/2024 LPA reviewed S1's employee file and did not see any disiplinay actions for misconduct. LPA also interviewed ED who expressed that there has been an ongoing issue with an individual making false allegations against S1. Report continues on LIC 9099-C Unsubstantiated On 10/14/2024 LPA spoke with W1 over the phone who initially stated that S1 was taking pictures of residents apartments and was stealing blankets from their rooms. LPA requested that W1 send the pictures to them so they could verify this information. LPA never received pictures although W1 said they had access to them. When LPA called W1 back they stated that they have been advised to not discuss the matter further by police. LPA submitted a request to San Ramon Police Department for records related to S1 and any allegations and did not receive anything back. LPA spoke with ED and found that there were no reports of residents missing any blankets or other items from their rooms. Any items that were reported lost for residents were found and deemed to have been misplaced. S1 no longer works at the facility and resigned after taking a leave of absence for 2 weeks. S1 took a leave of absence due to the harassment from the individual making false claims. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 13, 2025 · control 15-AS-20241007150646

Type of visit: Case Management - Incident

On 8/19/2024 at 12:00pm Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit as a result of an Unusual Incident Report received 8/09/2024. LPA met with Regional Operations Specialist, Pari Manouchehri and Health Service Director, Anlisse Ramirez and explained the purpose of the visit. The current census is 140. On 9/9/2024 the department received an unusual incident report that stated "Resident (R1) was climbing walls outside the community and entering neighboring homes. (R1) was not responding to staff while running into the street. (R1) was jumping on parked cars; jumped into a car and was flipping off staff and passersby. Resident had just moved in less than 24 hours prior and had a clear 602, assessment and smooth move in. (R1's) behaviors were a direct contradiction to the totality of information gathered prior to move in." LPA reviewed R1's 602 (Physicians report). The 602 stated that R1 could leave unassisted and R1 was independent. R1 did not sustain any injuries. R1 has since been diagnosed with unspecified Schizophrenia and no longer resides at the facility. On 8/3/2024 and 8/6/2024 the facility retrained staff on elopement procedures. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 19, 2024

Type of visit: Case Management - Incident

On 8/19/2024 at 1:05pm Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit as a result of an Unusual Incident Report received 7/22/2024. LPA met with Regional Operations Specialist, Pari Manouchehri and Health Service Director, Anlisse Ramirez and explained the purpose of the visit. The current census is 140. It was reported that on 7/16/2024 R1 had their purse, phone, wallet and its contents stolen by S1. LPA obtained S1's personnel file for review. S1 has since been terminated. R1 did not wish to be interviewed. R1 left their personal belongings in the dining area where S1 took them when no one was around. LPA will return at a later date to conduct another case management visit. Facility retrained staff on reporting requirements and procedures on what to do when finding items at the facility. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 19, 2024

Allegation investigated: Fire Exit is being blocked

On 6/13/2024 at 12:00 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct an initial 10 day complaint visit and deliver findings. LPA explained the purpose of the visit to Director of Transitions & Acquisitions, Michael Fountain LPA toured the facility with Director including but not limited to stairwells, common areas, and kitchen. During tour LPA observed a shampoo machine to be blocking fire exit located in 1st floor stairwell behind door 6. During the 10-day complaint visit LPA obtained a copy of facility map. The department also received a photo showing the same carpet shampooer located in the stairwell behind door 6 on a different occasion. Based on LPAs observations, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Substantiatedthe state’s words, verbatim · CDSS document, Jun 13, 2024 · control 15-AS-20240603145326

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jun 13, 2024

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic This requirement is not met as evidence by: Based on observation the fire exit in stairwell behind door six was blocked by an industrial shampoo machine which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 13, 2024

Plan of correction: Staff removed and stored shampooer in a safe location not blocking a fire exit.

Type of visit: Case Management - Incident

On 3/27/2024 at 1:50 PM Licensing Program Analyst (LPA) A. Gomez arrived unannounced to continue a Case Management visit in regards to an unusual incident report received 2/06/2024. LPA met with Executive Director, Caroline Frangieh and explained the purpose of the visit. It was reported that on 02/02/2024 that a team member allegedly observed another team member push a resident living in memory care. It was found that the incident actually occurred 1/31/2024. Resident was observed to have no injuries or recollection of the event. Resident did not fall as they were near a wall and was able to stabilize thyself. Health Services Director, Anelisse Ramirez-LVN, was called to assess for possible injuries. Assessment resulted in no visible injuries. Resident was asked about the event, which they were unable to recall. LPA interviewed witness S2 with the help of Health Services Director, Anelisse Ramirez to translate. S2 stated that while they were pushing the dish cart from the kitchen R1 was wandering in their briefs and approached S2 to ask a question. S2 responded with "OK" because they do not speak English. S2 then returned to the kitchen and came back out a few minutes later. S2 then observed R1 walking down the hall towards S1 who was looking at their phone. S1 ignored R1. S2 speculates that R1 was asking S1 to go to the bathroom based on the body language of R1. R1 raised their voice repeatedly to get the attention of S1 but S1 maintained looking at their phone. S1 then reached over to the left with phone still in hand to push R1 away. R1 then stumbled and braced thyself against the wall. S2 states that R1 looked down after balancing thyself and then walked away. S1 then made eye contact with S2 and rolled their eyes. S2 later reported what they witnessed. Report continues on LIC 809-C Resident was in memory care and unable to recall. At the time of visit resident was no longer at the facility. LPA spoke with ED about addressing reporting requirements for mandated reporters and ED informed LPA that they provided S2 as well as all facility staff with a training on the expectations. THE FOLLOWING DEFICIENCIES ARE BEING CITED S1 was observed physically abusing R1 The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 27, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(10) · Plan of correction due date: Mar 28, 2024

To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by: Based on interviews and reports S1 pushed R1 thereby physically abusing them.the state’s words, verbatim · CDSS document, Mar 27, 2024

Plan of correction: Staff was terminated.

Type of visit: Case Management - Annual Continuation

On 03/27/2024 at 9:30AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to continue the 1-Year Annual Required inspection. LPA met with Executive Director, Caroline Frangieh and explained the purpose of the visit. The facility’s fire clearance was approved for 162. Smoke detectors are interconnected with sprinklers and observed throughout the facility. Fire extinguisher was last serviced on 5/23/2023. Fire Drill was last conducted on 12/22/2023. Emergency Disaster Plan was last posted on 2/28/2024. At 11:20AM, LPA reviewed 8 residents records. At 3:20PM, LPA reviewed 5 staff records. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 11:45 AM during file review LPA observed R1's physician report designating them as bedridden. R1 resides in room 194 which is not cleared for bedridden (Immediate $500 civil penalty) 87202(a)(2) At 3:20 PM during staff file review LPA observed that S2 and S3 do not have first aid training's and requirements on file. At 3:25 PM during staff file review LPA observed that S2 and S4 do not have a heath screen or TB result on file ***Immediate $500 Civil Penalty Assessed for Fire Clearance Violation*** The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 27, 2024

Type of visit: Case Management - Incident

On 2/28/2024 at 11:16 AM Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a Case Management visit in regards to an unusual incident report received 2/06/2024. LPA met with Executive Director, Caroline Frangieh and explained the purpose of the visit. It was reported that on 02/02/2024 that a team member allegedly observed another team member push a resident living in memory care.Resident was observed to have no injuries or recollection of the event. Resident did not fall as they were near a wall and was able to stabilize thyself. Health Services Director, Anelisse Ramirez-LVN, was called to assess for possible injuries. Assessment resulted in no visible injuries. Resident was asked about the event, which they were unable to recall. The staff (S1) alleged of abuse was terminated effective 2/12/2024. LPA obtained a copy of the Disciplinary Action Notice for S1 and contact information for witnesses and all parties involved. LPA will return at a later date to continue investigation. No Deficiencies will be cited at this time Exit interview conducted. A copy of this report provided via e-mail.the state’s words, verbatim · CDSS document, Feb 28, 2024

Type of visit: Required - 1 Year

On 02/28/2024 at 1:30PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Caroline Frangieh and explained the purpose of the visit. The facility’s fire clearance was approved for 140. LPA toured the facility with Caroline Frangieh including but not limited to 10 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 78 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 114.1, 112, 113.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. No citations issued during inspection. Required Annual Inspection incomplete. LPA shall return unannounced to complete the inspection at a later date and time. Exit interview conducted with Licensee. A copy of this report provided to the Licensee via email.the state’s words, verbatim · CDSS document, Feb 28, 2024

Type of visit: Case Management - Incident

On 1/17/2024 at 1:30 PM Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a Case Management visit in regards to an unusual incident report received 11/11/2023. LPA met with Executive Director, Caroline Frangieh, and explained the purpose of the visit. It was reported that on 11/10/2023 resident (R1) went awol from facility. At approximately 7:15AM the door alarm near apartment 285 went off. When facility staff went to look for R1 they were not found in their apartment. At approximately 7:30AM R1 was located in facility parking lot. During visit LPA reviewed R1's physicians report and care plan. R1's physicians report states that R1 is able to leave the facility unassisted. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Jan 17, 2024

Allegation investigated: Facility in disrepair. Facility is malodorous.

On 10/20/2023 at 9:30 AM Licensing Program Analysts (LPAs) P. Watson and A. Gomez arrived unannounced to conduct a complaint investigation for the above allegations. LPAs met with Executive Director, Melissa Del Dosso, and explained the purpose of the visit. During the course of the investigation, LPAs toured facility and interviewed staff and residents. It was alleged that Facility in disrepair and Facility is malodorous, based on interviews with staff (S2, S3, S4 and S5), the exhaust fans in the kitchen have been broke for about a week. S4 stated that the facility has contacted Cintas to inspect and repair the fan, S4 has reached out to the company multiple times and is waiting for a call back. Report continues on 9099 C Unsubstantiated S3 and S4 stated that the facility has taken action to alleviate any odor that has been caused by the disrepair such as opening doors and windows and placing a fan in the kitchen area to blow the smell away from dinning area. S2 and S3 stated that the smell is primarily in the kitchen area and can be smelled when kitchen staff open the doors to deliver food. S5 stated that at one point the odor did linger into the hallway closets to the kitchen area but recently they have not smelled any odors. Based on interviews with residents, R4 stated that they were informed by staff that the exhaust fan in the kitchen was broken and that there may be an odor, R4 stated that they smelled a slight odor in the kitchen area at one point but did not smell anything recently. Based on LPAs observations and interviews, although the allegations may have happened or is valid, the facility is taking action to make repairs and alleviate odors, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 20, 2023 · control 15-AS-20231016103234

Type of visit: Case Management - Deficiencies

On 10/20/2023 at 12:30 PM Licensing Program Analysts (LPAs) P. Watson and A. Gomez arrived unannounced to conduct a Case Management inspection. LPAs met with Executive Director, Melissa Del Dosso, and explained the purpose of the visit. While LPAs were conducting another visit in the facility, LPAs were informed of the following deficiency. -Facility has an approved fire clearance capacity for 140 residents, however the facilities current census is 143. An immediate civil penalty will be assessed today of $500. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Exit interview conducted, appeal rights and copy of this report provided.the state’s words, verbatim · CDSS document, Oct 20, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Oct 21, 2023

87202(a) Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal... Based on interview, the licensee did not comply with the fire clearance. The facility has an approved fire clearance for a capacity of 140, however the facilities current census is 143 which poses/posed an immediate Health, Safety or Personal Rights risk to persons in carethe state’s words, verbatim · CDSS document, Oct 20, 2023

Plan of correction: Administrator will submit a capacity increase to CCL by POC date An immediate $500 civil penalty is being assessed today