Ivy Park at San Tomas

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced visit to amend complaint report 26-AS-20250909093332. LPA met with Business Office Manager Maribel Abinsay and stated the purpose of the visit. LPA delivered an amended complaint report for complaint number 26-AS-20250909093332. LPA reviewed amended complaint report with Business Office Manager. A copy of the amended complaint report 26-AS-20250909093332 dated 9/4/2026 was provided to Business Office Manager during today's visit. No deficiencies were cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with Business Office Manager Maribel Abinsay and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 4, 2026

Type of visit: Case Management - Legal/Non-compliance

On 08/26/2026, San Bruno Regional Office-San Jose Unit conducted a non-compliance conference meeting with, Jenn Sato, Senior Vice President (SVP) Health Services, Scott Carlson SVP Operations, Sue Mchperson SVP Quality Assurance and Regulatory Affair, Safoora Ahmed, Vice President (VP) of Memory Care and Programming, Rina Younan, VP Program Development, Kevin Wrigley, VP of Regulatory, Joel Goldman, Partner/Hanson Bridgett. Present in the meeting were Regional Manager (RM) Jackie Jin, Regional Manager Licensing Program Manager(LPM) Christine Kabariti, and Licensing Program Analyst (LPA) Marcela Yanez. During the non-compliance meeting, the following serious violations were discussed: 87463(a) Reappraisals, 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities 87303(a) Maintenance and Operation, 87705(e)(3) Care of Persons with Dementia During this meeting, the compliance plan was developed and discussed with the licensee which includes more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations: https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers This report was reviewed with Jenn Sato, Senior Vice President (SVP) Health Services, Scott Carlson SVP Operations, Rina Younan, Managing Director and Safoora Ahmed Vice President of memory Care and Programming. A copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 26, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced visit to amend complaint report 26-AS-20260126122429 and Case Management visit on 8/12/2026. LPA met with Executive Director (ED) Karen Nickolai and stated the purpose of the visit. LPA delivered an amended report for complaint number 26-AS-20260126122429 and an amended report for a Case Management visit on 8/12/2026. No deficiencies were cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with Executive Director (ED) Karen Nickolai and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 21, 2026

Allegation investigated: Due to lack of supervision, the resident fell sustaining an injury.

*This is an amended report* Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to deliver complaint findings. LPA met with Executive Director (ED) Karen Nickolai. LPA stated the purpose of the visit. On 1/26/2026 the Department received a complaint with the above allegation. It has been alleged that due to lack of supervision, a resident, referred to as R1, fell three times on 10/17/2025, 10/21/2025, and 10/26/2025. During R1's fall on 10/26/2025, R1 sustained a fractured vertebra (neck) during a fall while in care. On 1/27/2026 the Department conducted the initial complaint investigation visit and met with ED Karen Nickolai. The Department obtained pertinent documentation. Page 1 of 3 Substantiated *This is an amended report* Review of R1’s documentation dated 2/10/2025 and 2/14/2025, R1 has a history of falling. R1’s Assessment Form dated 2/14/2025, R1 is a fall risk, and requires queuing for transfers, requires status check every shift (Fall risk). R1’s Individual Service Plan dated 9/25/2025, R1 is noted as high fall risk and is under fall management to be provided by care provider. R1’s charting notes that R1 fell while in care on the following dates: 10/17/2025, R1 fell hitting his/her head, with a laceration on temple, 10/26/2025 R1 fell while attempting to get out of bed, hitting her/her head and required medical attention. R1’s charting notes also note that R1 fell in care on 6/3/2025 hitting the left side of his/her body on the floor, and on 9/24/2025 R1 had another fall, resulting in a laceration on the left elbow. Review of additional records for R1, note that R1 fell on 10/21/2025, hitting his/her head, which was not noted on R1’s charting notes. Review of medical documents dated 10/26/2025, R1 sustained a fractured vertebra (neck), due to a fall at the facility. On 7/8/2026, 7/27/2026, and 8/3/2026 the Department interviewed 5 Staff (S1 to S5). 5 Out of 5 did not know if facility management had conducted a fall assessment when R1 fell on 10/17/2025, 10/21/2025 and 10/26/2025. Based on interviews with staff, S4 stated that R1 was a known fall risk because R1’s health was declining. S4 states that in October 2025, the facility did not have a health services director and had regional management staff supporting the facility. S4 states to have voiced concerns about R1’s falling to the regional corporate staff. S4 believed the regional corporate staff were aware of R1’s condition, however, S4 was not able to confirm if R1 had a new care plan and does not believe there were any fall preventions or new assessments for R1. Based on interview with staff S5, it was stated that R1 was a known fall risk. S5 states a fall assessment should be conducted after every fall, and the fall assessments are completed by upper management. Page 2 of 3 *This is an amended report * S5 states to have verbalized concerns about R1’s falls to the regional management but does not remember receiving any new directives for R1’s fall management. S5 states that during his/her month of employment, the senior management was short staffed as there was no permanent senior wellness nurse to report to consistently. Although corporate sent different regional nurses for coverage from September 2025 – October 2025, S5 states to have felt understaffed because he/she was responsible for overseeing memory care and assisted living residents and staff, when S5 was “barely” trained. Based on review of R1’s records, there are no documented reassessments or additional fall prevention measures after R1 fell on 10/17/2025 and 10/21/2025. Based on observations, interviews conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency was cited per California Code of Regulations, Title 22. See LIC 9099D. A separate case management visit was conducted on 08/12/2026 due to a violation found during the investigation. An immediate civil penalty of $500 is being assessed today for serious bodily injury. Additional civil penalties are pending review. An exit interview was conducted with Executive Director (ED) Karen Nickolai. A signed copy of this report and appeal rights were provided. On 2/19/2026 and 8/12/2026 the Department reviewed 3 staff records. 3 Out of 3 staff have training documented for 2025 and 2026 to include but not limited to transfers, dementia behaviors. Staff in-service training records from January 2026 to July 2026 were reviewed, topics included but not limited to elopement drills, fall management protocols. Staff do not follow residents’ care plans RP states Resident R1 fell due to staff not knowing how to care for R1 as a fall risk. On 1/27/2026 and 2/19/2026 the Department interviewed 3 staff (S1 to S3). 3 Out of 3 Staff stated he/she has training on resident fall prevention/protocols. 3 Out of 3 staff stated he/she can obtain information about resident’s care plans in the resident’s binders, as well as reviewing resident progress notes. On 7/8/2026 and 8/12/2026 the Department interviewed 5 Residents (R2 to R6). 5 out of 5 residents stated he/she does not have any concerns with the care he/she is receiving. On 2/19/2026 and 8/12/2026 the Department reviewed 3 staff records. 3 Out of 3 staff have training documented to include but not limited to transfers, dementia behaviors for 2025 and 2026. Staff in-service training records from January 2026 to July 2026 were reviewed, topics included but not limited to elopement drills, fall management protocols. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director (ED) Karen Nickolai and a copy of this report was provided. Page 2 of 2 END OF REPORT This agency has investigated the complaint alleging staff installed cameras in residents’ room without consent We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Executive Director (ED) Karen Nickolai and a copy of this report was provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, Aug 12, 2026 · control 26-AS-20260126122429

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 13, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (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: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This was not met as evidenced by:the state’s words, verbatim · CDSS document, Aug 12, 2026

Plan of correction: Licensee will submit a plan of action stating how they will ensure the personal rights of residents are upheld, including the right to care, supervision and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency. to meet their needs. POC due by POC due date 8/13/2026. *This is an amended deficiency* Based on interviews and record review, the licensee did not comply with the section cited above wherein the management staff was not competent to provide the care and supervision to meet resident (R1)’s needs after being informed of concerns by staff of resident (R1) being a fall risk resulting in R1 sustaining a fractured vertebra which poses an immediate health, safety, and personal rights risk to persons in care.

Type of visit: Case Management - Deficiencies

*This is an amended report* Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a case management – other visit. LPA met with Executive Director (ED) Karen Nickolai. LPA stated the purpose of the visit. The purpose of the visit is to amend the Type B deficiency issued on 7/29/2026 back to a Type A deficiency, initially issued on 5/21/2025, to resolve an appeal granted by Community Care Licensing Division (CCLD) on 6/17/2026. On 05/21/2025, the facility was cited for a Type A deficiency in violation of Title 22 Section 87309(a). On 6/9/2026 the facility submitted an appeal to the Department and requested the deficiency to be lowered from a Type A to a Type B. On 06/17/2026, the Department granted the appeal to be lowered to a Type B deficiency. On 07/29/2026, a Type B deficiency was issued. The Type A deficiency on visit date of 05/21/2025 will be dismissed. This report was reviewed with Executive Director (ED) Karen Nickolai and a copy of the report, amended LIC809D for Type A deficiency 5/21/2025.the state’s words, verbatim · CDSS document, Aug 12, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marcella Tarin conducted a Case Management visit-Other for a deficiency observed during a complaint investigation visit on 8/12/2026 for 26-AS-20260126122429. A resident, referred to as R1, fell three times while in care on 10/17/2025, 10/21/2025, and 10/26/2025. On 7/8/2026 and 7/27/2026 the Department interviewed 5 Staff (S1 to S5). 5 Out of 5 stated R1's fall prevention was increased supervision by checking on R1 every two hours, as well as having R1 around staff and other residents. 5 Out of 5 staff did not know if facility management had conducted and documented a fall assessment after R1's falls on 10/17/2025 and 10/21/2025. Review of documentation, notes R1’s Individual Service Plan was last updated on 9/25/2025, R1 is noted as high fall risk and is under fall management to be provided by care provider. On 8/12/2026 the Department interviewed ED and Health Services Director (HSD). ED and HSD states there were no documented reassessments or additional fall prevention measures after R1 fell on 10/17/2025 and 10/21/2025. A deficiency is being cited per California Code of Regulations, Title 22. An exit interview was conducted with Executive Director (ED) Karen Nickolai and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 12, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Aug 19, 2026

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement is not met as evidenced by: Based on record review and interview, ED and HSD stated there were no documented reassessments or additional fall prevention measures after R1 fell on 10/17/2025 and 10/21/2025.the state’s words, verbatim · CDSS document, Aug 12, 2026

Plan of correction: ED stated to submit a written plan of action stating understanding of the regulation cited and will submit a plan stating how the facility will ensure reappraisals are completed after a significant change to a resident. POC due by POC due date of 8/19/2026.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a case management – other visit. LPA met with Executive Director (ED) Karen Nickolai. LPA stated the purpose of the visit. The purpose of the visit is to amend the LIC809D page on visit 05/21/2025. On 05/21/2025, the facility was cited for a Type A deficiency in violation of Title 22 Section 87309(a). On June 9, 2025 the facility submitted an appeal to the Department and requested the deficiency to be lowered from a Type A to a Type B. On 06/17/2026, the Department granted the appeal to be lowered to a Type B deficiency. During today’s visit, the Type B deficiency of 87309(a) was issued per California Code of Regulations, Title 22. The Type A deficiency on visit date of 05/21/2025 will be dismissed. During today’s visit, the LIC9099 from complaint control number 26-AS-20250909093332 was also amended. This report was reviewed with Executive Director (ED) Karen Nickolai and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 29, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Aug 12, 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 is not met as evidenced by: Based on interview, record review and observation the licensee did not comply with the section cited above wherein chemicals and hygiene products were observed in 9 out of 11 dementia resident rooms which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2026

Plan of correction: Licensee states a plan to lock all chemicals/disinfectants. Licensee will submit a written plan and in-service staff training regarding the regulation cited to LPA Kabariti via email by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to deliver amended findings for complaint 26-AS-20250909093332, and to amend a Type A deficiency to a Type B deficiency for a Case Management (CM) visit conducted on 5/21/2025. LPA met with Executive Director (ED) Karen Nickolai. LPA stated the purpose of the visit. During today's visit LPA delivered amended complaint findings from unsubstantiated to substantiated for complaint for 26-AS-2025090909333. A deficiency is being issued for this complaint. LPA amended a Type A deficiency issued on 5/21/2025 to a Type B deficiency. An amended LIC809D was provided to ED during today's visit. A deficiency is being cited during today's visit for complaint 26-AS-20250909093332 per California Code of Regulations, Title 22. See LIC809D for more information. An exit interview was conducted with ED Karen Nickolai, a copy of this report and appeals rights were provided.the state’s words, verbatim · CDSS document, Jul 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jul 18, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This was not met as evidenced by: Based on interview, record review and observation the licensee did not comply with the section cited above when R1's room was observed soiled with feces on 9/2/2025, and was reported to Executive Director (ED) on 9/3/2025. ED stated she cleaned R1's room on 9/3/2025 when reported.the state’s words, verbatim · CDSS document, Jul 17, 2026

Plan of correction: Licensee will submit a plan of action on how the facility will ensure resident's rooms are clean, safe, sanitary and in good repair at all times. Licensee to submit POC by POC due date 7/18/2026.

Allegation investigated: Staff do not provide adequate supervision resulting in resident eloping from the facility

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Karen Nickolai, Administrator. On 03/27/2026, LPA Marrufo conducted an initial complaint investigation visit. On 03/27/2026, LPA Marrufo obtained a copy of R1’s Physician’s Report. R1’s Physician’s Report states R1 has a primary diagnosis of dementia and is not able to leave the facility unsupervised. See LIC9099-C page for more information. Page 1 of 4. Substantiated On 03/27/2026, LPA Marrufo obtained a copy of R1’s Individualized Service Plan (ISP), dated 08/21/2025. The Wandering section of R1’s ISP states, “Resident wanders into apartments agitating other residents. Receives observation and assistance when wandering.” The Exit Seeking section states, “Resident verbalizes desire to leave, may seek out exit doors throughout the day; will peer through door windows or loiter near exit but does not attempt to leave secured area, requiring no additional staff time. Receives observation and assistance when seeking exits. Closely observe and guide when seeking exits. Cue or redirect for safety. Resident need[s] to be on frequent checks. Lacks safety judgements.” On 03/25/2026, the facility submitted an Unusual Incident/Injury Report (IR). The IR was submitted on 03/25/2026. The IR states that on 03/24/2026, staff last observed R1 near the Activities Director on the first floor around 4:00 PM and was brought upstairs to memory care by the Activities Director. Around 5:00 PM, staff noted R1 was missing from the Memory Care Unit. Staff called 911. Around 6:30 PM, police officers located R1 on Doyle Road. On 03/27/2026, LPA Marrufo interviewed S1-S9. During interviews, S4, S7, S8, and S9 stated to have been involved with R1’s elopement from the facility on 03/24/2026. During interview, S4 stated R1 took the stairway down from the Memory Care unit on the second floor to the first floor and exited the facility building through an emergency exit. S4 stated none of the staff heard the emergency exit door alarm. S4 stated he/she and other staff searched each resident room of the facility looking for R1 and then began to search for R1 in the surrounding community outside the facility building. S4 stated police found R1. During interview, S7 stated that he/she was driving away from the facility when staff called him/her and notified him/her that R1 had eloped from the facility. S7 stated R1 had eloped from the facility about five minutes prior to S7 receiving the call from staff. S7 stated he/she began driving back to the facility while instructing staff to utilize the elopement bin, which includes the elopement checklist. Page 2 of 4. During interview, S8 stated he/she is the Activities Director. S8 stated he/she had taken R1 out of the facility for an outing and returned with R1 at around 3:30 PM. S8 stated he/she walked R1 back up to the Memory Care unit of the facility on the second floor. S8 stated he/she later observed R1 with another resident in the art studio on the first floor. S8 stated he/she walked R1 and the other resident back up to the activity room in the second floor. S8 stated that when he/she arrived to the second floor activity room, he/she made eye contact with the staff inside the activity room and told the staff that R1 and the other resident were now with him/her. S8 stated staff began searching for R1 after S8 had left the facility around 5:00 PM. During interview, S9 stated that prior to R1’s elopement on 03/24/2026, R1 has had previous elopement attempts. S9 stated that R1 has made previous attempts to exit through the exit door that is at the end of the stairway at the end of the hall. S9 stated staff usually redirect R1 when he/she is going down the stairs or is at the door. S9 stated there have been times when R1 reaches the door and opens it, but the exit alarm startles R1 and he/she does not leave the facility. S9 stated that on 03/24/2026, he/she was in another resident’s room while that resident’s family member was visiting. S9 stated the resident’s family member said he/she heard an alarm, but S9 did not hear it. S9 stated that R1 was under his/her charge so he/she went to look for R1 in every apartment in the upstairs and downstairs levels in the facility. S9 stated after searching for R1 for around 20-30 minutes, he/she notified the medication technician on duty. S9 stated the medication technician then notified the rest of the staff on duty that R1 had gone missing. S9 stated he/she believes ADM was notified around the same time S9 had notified the medication technician. S9 stated he/she did not inform ADM because he/she assumed someone else had already done so. During visit on 03/27/2026, LPA Marrufo interviewed ADM. During interview, ADM stated R1 eloped through the side exit and set off the door alarm. ADM stated staff did not notify ADM of R1’s elopement until 30 minutes after staff realized R1 had eloped. ADM stated she immediately called 911 and used her personal vehicle to look for R1 in the neighborhood surrounding the facility. ADM stated police officers found R1 and brought R1 back to the facility. Page 3 of 4. END REPORT During visit on 03/27/2026, LPA Marrufo interviewed residents R2-R5. During interviews, R2-R5 stated they have not observed a resident being left on the floor for an extended period. During visit on 03/27/2026, LPA Marrufo interviewed staff S1-S9. During interview, S1-S9 stated to have not observed a resident left on the floor for an extended period of time. S2 and S7 stated staff are alerted and are able to see a video of resident falls. During visit on 03/27/2026, LPA Marrufo interviewed Administrator (ADM) Karen Nickolai. During interview, ADM stated that she has not observed residents being left on the floor for an extended period of time. On 05/28/2026, LPA Marrufo conducted telephone interviews with FM1, family member of R6, FM2, family member of R7 and FM3, family member of R8. During interviews, FM1-3 stated to have not observed residents being left on the floor for an extended period of time. Allegation: Staff do not prevent residents from harming themselves When the department received the complaint, it was alleged that residents commit suicide on premises. During visit on 03/27/2026, R2-R5 stated they have not observed any residents attempt suicide at the facility. During visit on 03/27/2026, S1-S9 stated no residents have attempted suicide at the facility. During visit on 03/27/2026, ADM stated no residents have attempted suicide at the facility. On 05/28/2026, LPA Marrufo conducted telephone interviews with FM1, family member of R6, FM2, family member of R7, and FM3, family member of R8. During interviews, FM1-3 stated to have not observed residents attempt suicide at the facility or staff not preventing residents from harming themselves. On 05/28/2026, LPA Marrufo obtained copies of Internal Incident Reports and Unusual Incident/Injury Reports from February and March 2026 and did not observe any reports of residents posing a danger to themselves. This agency has investigated the complaint allegations listed. Based on interviews and review of records, the agency has found that the complaint allegations are unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. This report was reviewed with Karen Nickolai and a copy of this report was provided. Page 2 of 2. END REPORT. Based on records review and interviews, there is preponderance of evidence to prove the alleged violation did occur. Therefore, the allegation is substantiated. See LIC9099-D for a deficiency cited per the California Code of Regulations, Title 22. This report was reviewed with Administrator Karen Nickolai and a copy of this report and appeal rights were provided. Page 4 of 4. END REPORTthe state’s words, verbatim · CDSS document, May 28, 2026 · control 26-AS-20260325084408

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(e)(3) · Plan of correction due date: May 29, 2026

Care of Persons with Dementia (e) Licensees that use delayed egress devices on exterior doors and perimeter fence gates shall meet the following initial and continuing requirements: (3) Facility staff shall attempt to redirect a resident at risk for elopement who may be attempting to leave the facility without violating Section 87468.1, Personal Rights of Residents in All Facilities. This requirement was not met as evidenced by: Licensee did not ensure that facility staff redirected R1 as he/she left the facility, posing an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, May 28, 2026

Plan of correction: Licensee agrees to submit a Plan of Correction by 05/29/2026 stating how the licensee will conduct in-service training with staff on ensuring that staff redirect a resident at risk for elopement who may be attempting to leave the facility. Once training is complete, the licensee agrees to submit training records that include name of staff trained, training dates, training topics, and names and qualifications of trainers.

Allegation investigated: Facility did not reassess resident after resident experienced a change in health condition.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced visit to deliver complaint findings. LPA me with Executive Director (ED) Karen Nickolai. LPA stated the purpose of the visit. On 2/09/2026 the Department received a complaint with the above allegation. On 2/09/2026 and 2/19/2026 the Department interviewed the Reporting Party (RP). RP stated a resident, referred to as R1, had a fall on 10/27/2025 while in care at the facility, which resulted in R1 being hospitalized. RP stated the facility did not assess R1 after being accepted back into the facility after being hospitalized. Page 1 of 2 Unsubstantiated On 2/19/2026, the Department conducted the initial complaint investigation visit and requested pertinent documentation. The Department interviewed 3 Staff (S1 to S3). 3 Out of 3 staff stated residents are assessed after having a fall. On 5/26/2026 the Department interviewed Executive Director (ED) Karen Nickolai. ED stated R1 fell on 10/26/2025 and was hospitalized. ED stated R1 did not return to the facility after the fall on 10/26/2025. ED stated a 30 days notice was given for R1 on 10/28/2025. Review of R1's care notes, R1 fell on 10/26/2025 and was sent out to the hospital. Review of medical documentation dated 10/26/2025, R1's physician notes that R1 requires a '24/7 caregiver in place', "need of higher level of care." Review of Resident Charges/Payments Ledger for R1, notes 'Notice Given: 10/28/2025, Notice For: 11/28/2025.' On 5/26/2026, the Department conducted an additional interview with RP. RP stated R1 did not return to the facility after falling on 10/27/2025 due to R1 needing a higher level of care. RP stated R1's "needs exceeded Ivy Park." Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director (ED) and a copy of this report was provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, May 26, 2026 · control 26-AS-20260209115931

Allegation investigated: Facility staff did not ensure resident's feeding needs were met

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Maribel Abinsay. On 11/05/2025, the department received a complaint with the above allegations. On 11/06/2025, LPA Marrufo conducted an initial complaint investigation visit. On 05/14/2026, LPA Marrufo conducted an additional complaint investigation visit. When the department received the complaint, it was alleged that facility staff were not feeding resident R1. On 11/06/2025, LPA Marrufo obtained a copy of R1’s Admission Agreement, which was signed on 07/17/2025. See LIC9099-C page for more information. Page 1 of 2. Unfounded On 11/06/2025, LPA Marrufo obtained a copy of R1’s Physician’s Report, which has an exam date of 07/16/2025. R1’s Physician’s Report stated R1 did not have a special diet. The Functional Capabilities section of R1’s Physician’s Report left the box next to “Unable to Feed Self” unchecked. On 11/06/2025, LPA Marrufo obtained a copy of R1’s Individualized Service Plan, dated 07/19/2025. The Eating section states, “No assistance required with eating. Resident will eat independently.” The Tray Service section states, “Resident does not require or request tray service. Resident attends meals independently.” The Dietary section states, “Regular menu; no special diet required. Resident eats a normal diet.” The Escorting section states, “Can walk to dining room and all activities within the facility, may need occasional reminder and/or escort. [Resident] maintains ability to attend meals and activities of choice.” On 11/06/2025, LPA Marrufo interviewed staff S1-S4. During interviews, S1-S4 stated they had regularly fed R1 and never neglected to feed R1. On 03/27/2026, LPA Marrufo conducted an interview with R1’s Family Member, FM1. During interview, FM1 stated staff regularly fed R1 and never neglected to feed R1. On 05/15/2026, LPA Marrufo conducted a telephone interview with Administrator (ADM) Karen Nickolai. During interview, she stated staff regularly fed R1 and never neglected to feed R1. On 05/15/2026, LPA Marrufo conducted a telephone interview with R1’s family member, FM2. During interview, FM2 stated R1 would call FM2 daily and ask FM2 to send R1 food. FM2 stated he/she was not sure if the facility neglected to feed R1 because FM2 was not always at the facility. This agency has investigated the complaint allegation listed. Based on interviews and review of records, the department has found that the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This report was reviewed with Maribel Abinsay and a copy of this report was provided. Page 2 of 2. END REPORT Based on information from interviews and records reviewed, although the allegation listed above 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 were cited under California Code of Regulations Title 22 This report was reviewed with Maribel Abinsay and a copy of this report was provided. Page 3 of 3. END REPORT The Bathing section of R1’s Individualized Service Plan states, “Requires stand-by assistance for all showering/bathing needs (1-2x/week). Maintains independence, and is clean, neat and odor free. Set up and stand-by for shower or bath.” The Dressing section of R1’s Individual Service Plan states, “No assistance required with dressing needs. Resident will dress independently.” During interviews on 11/06/2025, S1-S4 stated staff did not neglect R1’s hygiene needs and staff maintained R1’s shower schedule. S2 stated R1 needed assistance with showering, but R1 would sometimes shower himself/herself. S2 stated R1 would sometimes dress in two to three layers of clothes and staff would offer to help change R1, but R1 would refuse staff help. S3 stated staff applied lotion and deodorant on R1. S3 stated he/she never noticed R1 having bad body odor. S4 stated R1 would ask staff for extra showers in addition to R1’s shower schedule and S4 would assist R1 with showering outside his/her usual shower schedule. During interview on 03/27/2026, FM1 stated staff showered R1 every other day. FM1 stated he/she wanted staff to shower R1 daily, but staff told FM1 that R1’s agreement stated staff were to shower R1 every other day. FM1 stated staff did not neglect to meet R1’s hygiene needs. FM1 stated FM1 did not know if R1 had a foul body odor. During interview on 05/15/2026, ADM Nickolai stated staff regularly showered R1 and never neglected R1’s hygiene needs. ADM Nickolai stated she never observed R1 to have foul body odor. During interview on 05/15/2026, FM2 stated to have visited R1 every other day. FM2 stated he/she would often observe R1 with a foul body odor. FM2 stated R1 smelled like he/she had a soiled diaper. FM2 stated he/she attempted to take R1 out of the facility for lunch, but R1 had foul body odor. FM2 stated he/she would request staff to shower R1 and sometimes staff would assist with showering R1 and sometimes they would not. Page 2 of 3.the state’s words, verbatim · CDSS document, May 15, 2026 · control 26-AS-20251105115156

Allegation investigated: Staff do not ensure resident's rooms are clean/sanitary Staff did not ensure resident's hydration needs were met Staff does not ensure resident's are personal hygiene needs are being met.

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator Karen Nickolai On April 1, 2026, the Department received a complaint alleging Staff do not ensure resident's rooms are clean/sanitary. On April 2, 2026, Licensing Program Analyst Manuel Monter interviewed Witness W1. W1 stated he/she has found R1’s bedroom, as dirty and unsanitary. W1 stated he/she has found the bedsheets as soiled. W1 stated he/she has also noticed feces on the floor as well. W1 stated if staff are actively checking on R1’s bedrooms, then they would have noticed the soiled linens and the feces on the floor. Page 1 Out of 7 Unsubstantiated On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed residents R2-R4. 3 Out of 3 residents (R2-R4) stated they have not had any issues with the housekeeping and/or the cleanliness of his/her bedroom. On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Staff S1-S9. 9 Out of 9 staff (S1-S9) stated they have never seen a residents room’s cleaning neglected. 9 Out of 9 staff (S1-S9) stated have never seen or heard about any issues regarding the housekeeping of residents bedrooms and the facility as a whole. On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Maintenance Director Chavez, referred to as MD. MD stated he inspects all the residents bedrooms weekly. MD stated there hasn’t been an instance where he observed or heard about a residents bedroom being neglected or not clean. On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Resident Care Coordinator Esmeralda Lopez, referred to as RCC and Health Services Director Kyleigh Whitely. RCC and HSD stated they have never seen a residents room’s cleaning neglected. On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Administrator (ADM) Karen Nickolai. ADM stated when she first started as administrator (September 2025), there was issues with the housekeeping. ADM stated this was addressed. ADM stated she fired all the housekeeping and had hired 3 new housekeeping staff. ADM stated the facility hasn’t had any issues since then, in terms of keeping residents bedrooms clean. On April 9, 2026, Licensing Program Analyst Manuel Monter toured the facility inside and out with Administrator Karen Nickolai. LPA randomly toured the following but not limited to bedrooms: residents bedrooms on both the first and second floor: 201, 203, 229, 231, 233, 235, 238, 236, 211, 213, 215, 216, 220, 219, 226, 209, 207, 232, 234, 107, 109, 111, 113, 115, 114, 117, 119, 120, 104, 101. LPA did not observe any resident bedrooms as unsanitary/ unclean/ disrepair. On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed residents R1, R5-R9. 6 Out of 6 residents (R1,R5-R9) stated they have not had any issues with the housekeeping and/or the cleanliness of their bedroom. Page 2 Out of 7 On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed staff S10 and S11. 2 Out of 2 staff (S10-S11) stated they have not seen any instance were a resident’s bedroom was in an unsanitary state/neglected state. On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed Witness W2. W2 stated sometime in the beginning of March 2026, he/she did observe R1’s bedroom’s housekeeping needs as neglected. W2 stated he/she observed several dozens sheets of tissues on the floor. W2 stated after these 2 occasions, there hasn’t been any other issues regarding the housekeeping of R1’s room. The Department reviewed the facility’s Housekeeping Log for the month of March & April 2026. Based on a review, all bedrooms in the memory care unit are listed and checked if the bedroom houskeeping cleaned said bedroom. The log also notes any issues discovered by housekeeping and if a certain task was not completed or if a resident refused service that day. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Staff did not ensure resident's hydration needs were met On April 1, 2026, the Department received a complaint alleging Staff did not ensure resident's hydration needs were met On April 2, 2026, Licensing Program Analyst Manuel Monter interviewed Witness W1. W1 stated he/she believes the facility was not actively providing and offering his/her family member water. On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed residents R2-R4. 3 Out of 3 residents (R2-R4) stated they do not need assistance with eating or drinking. 3 Out of 3 residents (R2-R4) stated they are not aware of any issues of instances where residents were not assisted with meals and liquids. Page 3 Out of 7 On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Staff S1-S9. 9 Out of 9 staff (S1-S9) stated the staff is aware they need to offer the residents water and actively prompt memory care residents to drink and eat. 9 Out of 9 staff (S1-S9) stated they haven’t seen any residents that were neglected assistance with feeding and eating. On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Resident Care Coordinator Esmeralda Lopez, referred to as RCC. RCC stated during meal times, the caregivers will help the residents who, are known by the facility, who need assistance as part of their plan of care. RCC stated the care givers will also watch over the other residents. RCC stated if they see a resident who isn’t drinking their drink or eating their food, the staff will encourage them / remind them to drink/eat and assist if needed. RCC stated he/she hasn’t seen any residents that were neglected assistance with feeding and eating. On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Health Services Director Kyleigh Whitely, referred as HSD. HSD stated during meal times, the caregivers will help the residents who need assistance as part of their plan of care. HSD stated the care givers will also watch over the other residents. HSD stated if they see a resident who isn’t drinking their drink or eating their food, the staff will encourage them / remind them to drink/eat and assist if needed. HSD stated he/she hasn’t seen any residents that were neglected assistance with feeding and eating. On April 9, 2026, Licensing Program analyst Manuel Monter interviewed Administrator (ADM) Karen Nickolai. ADM stated all staff, even herself, are responsible for assistance in feeding and drinking water. ADM stated if they see a resident who isn’t drinking their drink or eating their food, the staff will encourage them / remind them to drink/eat and assist if needed. ADM stated he/she hasn’t seen any residents that were neglected assistance with feeding and eating. On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed residents R1, R5-R9. 6 Out of 6 residents (R1,R5-R9) stated the facility provides/offers residents with waters, including during and after activities. 5 Out of 6 residents (R1,R5-R7, R9) stated they do not need assistance with eating or drinking during meals. Resident R8 stated he/she does need assistance during meals, which includes assistance with drinking liquids. R8 stated here hasn’t been a time when she was not assisted or neglected during meals. Page 4 Out of 7 On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed staff S10 and S11. 2 Out of 2 staff (S10-S11) stated during breakfast, lunch dinner, staff assist residents. 2 Out of 2 staff (S10-S11) stated staff makes sure residents drink their liquids to stay hydrated. On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed Witness W2. W2 stated R1 doesn’t need assistance with eating or drinking. W2 stated he/she isn’t at the facility long enough to see if they are offering and queuing R1 to drink water. W1 stated he/she hasn’t noticed. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Staff does not ensure resident's are personal hygiene needs are being met. On April 2, 2026, Licensing Program Analyst Manuel Monter interviewed Witness W1. W1 stated he/she believes that the facility is not checking residents diapers and changing them every 2 hours. W1 stated almost every time he/she visits R1, he/she has found his/her soiled and wet. W1 stated it is possible his/her R1 had just wet him/herself. W1 stated he/she doesn't have the details of the times and dates when he/she found his/her R1 wet. W1 stated he/she has also observed that R1 has not had his/her cloths changed or his/her hair brushed on numerous occasions. W1 stated R1 would be wearing cloths in reverse such as shirts or pants. W1 stated he/she has found R1 not showered. W1 acknowledged that R1 will refuse showers as well. On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed residents R2-R4. 3 Out of 3 residents (R2-R4) stated they not need assistance with their grooming. 3 Out of 3 residents (R2-R4) stated they have not observed residents in a disheveled stated. Page 5 Out of 7. On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Staff S1-S9. 9 Out of 9 staff (S1-S9) stated there hasn’t been a time when they saw a resident that was neglected their showering needs. 9 Out of 9 staff (S1-S9) stated there hasn’t been a time when they saw a resident that was neglected residents grooming needs. 7 Out of 9 staff (S1-S5, S8-S9) stated there hasn’t been a time when he/she saw a resident who was neglected their changing needs or observed residents who’s changing needs were neglected for an extended period. 2 Out of 9 staff (S6-S7) stated they has observed instances where a resident was not changed, resulting in leaving a resident soiled for an extended period. S6 stated he/she has seen this happen once a month, due to previous shifts. S6 stated he/she can’t give an example of who in particular, since its sporadic. On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Resident Care Coordinator Esmeralda Lopez, referred to as RCC. RCC stated he/she has not observed any issues regarding the changing of residents. RCC stated there hasn’t been a time when he/she saw a resident who was neglected their changing needs or observed residents who’s changing needs were neglected for an extended period. On April 9, 2026, Licensing Program Analyst Manuel Monter interviewed Health Services Director Kyleigh Whitely, referred as HSD. HSD stated there hasn’t been a time when he/she saw a resident that was neglected their showering needs. HSD stated there hasn’t been a time when he/she saw a resident that was neglected residents grooming needs. HSD stated she hasn’t seen any residents who’s grooming needs were neglected. On April 9, 2026, Licensing Program Analyst Manuel Monter toured the facility inside and out with Administrator Karen Nickolai. LPA randomly toured the following but not limited to bedrooms: residents bedrooms on both the first and second floor: 201, 203, 229, 231, 233, 235, 238, 236, 211, 213, 215, 216, 220, 219, 226, 209, 207, 232, 234, 107, 109, 111, 113, 115, 114, 117, 119, 120, 104, 101. LPA did not observe any resident in a soiled, disheveled, or unkempt state. Page 6 Out of 7. On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed residents R1, R5-R9. 2 Out of 6 residents (R1,R5-R9) stated R1 R5 stated she doesn’t need assistance with grooming/bathing/ changing / using the restroom. 6 Out of 6 residents (R1, R5-R9) stated they haven’t’ seen any resident in a disheveled state or in a neglected state. 4 Out of 6 residents (R6-R9) stated they need assistance with showers. 3 Out of 6 residents (R6, R7, R9) stated there hasn’t been a time when she had missed a shower or was neglected bathing assistance. R8 stated there has been at least one time when he/she didn’t receive his/her shower. R8 stated his/her shower was scheduled for the morning and the staff offered to give it in the afternoon. R8 clarified he/she did receive his/her shower, but noted it was late. On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed staff S10 and S11. 2 Out of 2 staff (S10-S11) stated there hasn’t been a time when she saw a resident who’s grooming needs were neglected. 2 Out of 2 staff (S10-S11) stated there hasn’t been a time when a resident was neglected their showering needs. S10 stated there have been instances where he/she has found residents left soiled from the previous shift. S10 stated he/she can’t say for sure when this occurred. S10 stated this occurred 2-3 times since he/she has been working at the facility. S10 stated it hasn’t occurred since he/she complained to management about it. On April 17, 2026, Licensing Program Analyst Manuel Monter interviewed Witness W2. W2 stated there was two instances where he/she has found R1 soiled, fluids leaking from the place he/she was sitting. W2 stated he/she didn’t personally check or know if the soilage was fresh or had been there for some time. W2 stated this also occurred in the first weeks of March as well. W2 stated there hasn’t been any other issues with R1 being changed or groomed. W2 stated he/she hasn’t observed anything or noticed any issue. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 7 Out of 7.the state’s words, verbatim · CDSS document, May 11, 2026 · control 26-AS-20260401123849

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of a complaint investigation 26-AS-20260401123849. During the complaint investigation, a case management other visit was conducted due to discrepancies discovered during the investigation process. LPA met with Administrator Administrator Karen Nickolai. On April 13, 2026 the Department requested copies of the hospice notifications that were sent for residents R1-R3. On April 21, 2026, Health Services Director (HSD) Kyleigh Whitley informed LPA that the hospice notifications were not sent out for residents R1-R3. HSD stated she was unaware that the facility needed to send these hospice notifications to Licensing. On April 22, 2026, HSD submitted to LPA hospice notification forms for all residents currently under hospice. LPA also followed up regarding the pending death certificate requests for 4 residents. (R1-R4). A technical violation is being cited during today's visit per California Code of Regulations, Title 22. See LIC9102. This report was reviewed with Administrator Karen Nickolai and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 11, 2026

Allegation investigated: Staff did not change resident timely Resident missed medication Due to neglect, resident sustained a pressure injury Staff did not follow physician's orders Staff do not meet resident's feeding needs

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced complaint visit to deliver complaint findings. LPA met with Executive Director (ED) Karen Nickolai. LPA stated the purpose of the visit. On 4/11/2025 the Department received a complaint with the above allegations. On 4/18/2025 and 7/8/2025 the Department conducted complaint investigation visits, and interviewed 7 Staff (S1 to S7), 7 Residents (R1 to R7). On 4/22/2025, 4/2/2026, 4/3/2026, the Department interviewed Reporting Party (RP). RP states a resident, referred to as R1, was not changed in timely manner. Page 1 of 5 Unsubstantiated RP states R1 was left in soiled diapers for 12 hours on four occasions in April 2025. RP states these incidents were observed by a Private Caregiver (PCG) for R1. RP states he/she is unable to verify these incidents with the caregiver agency. On 4/18/2025 and 7/8/2025 the Department conducted complaint investigation visits, and interviewed 7 Staff (S1 to S7), 7 Residents (R1 to R7). 6 Out 7 staff state he/she changes residents every two hours. S6 states he/she observed a resident soiled on one occasion and reported the incident to facility management. S6 did not provide additional information regarding this incident. The Department interviewed 7 Residents (R1 to S7). 6 Out of 7 residents state he/she does not need assistance with toileting. R1 did not respond to questions due to neurocognitive impairment. Review of R1’s Preplacement Appraisal Information dated 7/16/2024, under Services Needed, ‘No’ is selected for toileting, and ‘YES’ selected for incontinence, ‘needs depends’ signed by RP and facility management. On 4/17/2026, the Department interviewed 1 Witness (W1). W1 stated the caregiver agency was no longer in business and did not provide any additional information. On 1/22/2026, 1/27/2026, 3/6/2026, 4/2/2026 and 4/9/2026 the Department requested additional documentation for R1 from Executive Director (ED) Karen Nickolai. On 4/22/2026, the ED states she was unable to locate documentation for R1 in storage. Resident missed medication On 4/22/2025, 4/2/2026, 4/3/2026, the Department interviewed the Reporting Party (RP). RP stated the facility did not follow R1’s medications orders, resulting in R1 not receiving his/her medications. RP did not provide additional information regarding these incidents. On 4/18/2025 and 7/8/2025 the Department conducted complaint investigation visits, and interviewed 7 Staff (S1 to S7), 8 Residents (R1 to R8). 6 Out of 7 staff state he/she is not aware of any issues with residents not receiving medications. S4 states he/she observed one medication error and reported it to facility management. S4 did not provide additional information regarding this incident. Page 2 of 5 The Department interviewed 7 Residents (S1 to S7). 6 Out 7 residents stated he/she does not have any issues with receiving his/her medications. R1 did not respond to questions due to neurocognitive disorder. Review of R1’s Medication Administration Record (MAR) for February 2025, medications were administered per doctor’s orders and no discrepancies were observed. On 1/22/2026, 1/27/2026, 3/6/2026, 4/2/2026 and 4/9/2026 the Department requested additional documentation for R1 from Executive Director (ED) Karen Nickolai. On 4/22/2026, the ED states she was unable to locate documentation for R1 in storage. Due to neglect, resident sustained a pressure injury On 4/22/2025, 4/2/2026, 4/3/2026, the Department interviewed the Reporting Party (RP). RP stated R1 sustained a pressure injury, ulcer in April 2025 due to staff not changing R1 in a timely manner. RP did not provide additional information regarding the pressure injury, ‘ulcer.’ On 4/18/2025 and 7/8/2025 the Department conducted complaint investigation visits, and interviewed 7 Staff (S1 to S7), 7 Residents (R1 to R7). 6 Out 7 staff state he/she changes residents every two hours. S5 states he/she has not observed residents who were neglected at any time. S6 states he/she observed a resident soiled on one occasion and reported the incident to facility management. S6 did not provide additional information regarding this incident. The Department interviewed 7 Residents (S1 to S7). 6 Out of 7 residents state he/she does not need assistance with toileting. R3 states if he/she did need toileting assistance, staff will help him/her. R1 did not respond to questions due to neurocognitive impairment. Review of R1’s Preplacement Appraisal Information dated 7/16/2024, under Services Needed, ‘No’ is selected for toileting, and ‘YES’ selected for incontinence, ‘needs depends’ signed by RP and facility management. LPA Tarin reviewed facility incident reports submitted to the Department for April 2025 and no noted incidents of any resident sustaining a pressure injury ‘ulcer’ while in care were observed. Page 3 of 5 On 1/22/2026, 1/27/2026, 3/6/2026, 4/2/2026 and 4/9/2026 the Department requested additional documentation for R1 from Executive Director (ED) Karen Nickolai. On 4/22/2026, the ED states she was unable to locate documentation for R1 in storage. Staff did not follow physician's orders On 4/22/2025, 4/2/2026, 4/3/2026, the Department interviewed the Reporting Party (RP). RP stated the facility did not follow R1’s medications orders, resulting in R1 not receiving his/her medications. RP did not provide additional information regarding these incidents. On 4/18/2025 and 7/8/2025 the Department conducted complaint investigation visits, and interviewed 7 Staff (S1 to S7), 8 Residents (R1 to R8). 6 Out of 7 staff state he/she is not aware of any issues with residents not receiving medications. S4 states he/she observed one medication error and reported it to facility management. S4 did not provide additional information regarding this incident. The Department interviewed 7 Residents (S1 to S7). 6 Out 7 residents stated he/she does not have any issues with receiving his/her medications. R1 did not respond to questions due to neurocognitive disorder. Review of R1’s Medication Administration Record (MAR) for February 2025, all medications were administered per doctor’s orders and no discrepancies were observed. On 4/17/2026, the Department interviewed 1 Witness (W1). W1 stated the caregiver agency was no longer in business and did not provide any additional information. On 1/22/2026, 1/27/2026, 3/6/2026, 4/2/2026 and 4/9/2026 the Department requested additional documentation for R1 from Executive Director (ED) Karen Nickolai. On 4/22/2026, the ED states she was unable to locate documentation for R1 in storage. Staff do not meet resident's feeding needs On 4/22/2025, 4/2/2026, 4/3/2026, the Department interviewed the Reporting Party (RP). RP stated he/she ‘believes’ R1’s weight loss in November 2024 was due to staff not providing assistance with eating. Page 4 of 5 On 4/18/2025 and 7/8/2025 the Department conducted complaint investigation visits, and interviewed 7 Staff (S1 to S7), 8 Residents (R1 to R8). 7 Out of 7 staff stated he/she provides feeding assistance to residents. The Department interviewed 7 Residents (S1 to S7). 6 Out 7 residents stated he/she does not have any issues with eating. R3 and R4 stated he/she has observed staff providing feeding assistance to residents. R1 did not respond to questions due to neurocognitive disorder. Review of R1’s Preplacement Appraisal Information dated 7/16/2024, under Services Needed, ‘No’ is selected for help with eating.’ Review of R1’s Change of Condition dated 11/14/2024, R1 is noted to not have a history of significant weight loss or weight gain. R1’s Meal Consumption Level of Assistance notes R1 to need ‘dining moderate assist, CM to cue resident throughout meals and snacks.” On 4/17/2026, the Department interviewed 1 Witness (W1). W1 stated the caregiver agency was no longer in business and did not provide any additional information. On 1/22/2026, 1/27/2026, 3/6/2026, 4/2/2026 and 4/9/2026 the Department requested additional documentation for R1 from Executive Director (ED) Karen Nickolai. On 4/22/2026, the ED states she was unable to locate documentation for R1 in storage. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with ED, and a copy of this report was provided. Page 5 of 5 END OF REPORTthe state’s words, verbatim · CDSS document, Apr 22, 2026 · control 26-AS-20250411110434

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management to address a deficiency observed during complaint 26-AS-20250411110434. LPA met with Executive Director (ED) Karen Nickolai. LPA stated the purpose of the visit. On 1/22/2026, 1/27/2026, 3/6/2026, 4/2/2026 and 4/9/2026 the Department requested via email additional documentation for a resident, referred to as R1, from Executive Director (ED) Karen Nickolai. LPA Tarin spoke with ED via phone call on 4/3/2026 and 4/9/2026. ED stated R1 was a resident ‘before her time’ and R1’s documentation was not at the facility, and possibly off-site in storage. On 4/22/2026, ED states she was unable to locate documentation for R1 in storage. A deficiency is being cited per California Code of Regulations, Title 22. See LIC809D for more information. An exit interview was conducted with ED, a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 22, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e)87506(e) · Plan of correction due date: Apr 29, 2026

87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This was not met as evidenced by: Based on interview and records reviews, on 1/22/2026, 1/27/2026, 3/6/2026, 4/2/2026 and 4/9/2026 the Department requested additional documentation for R1 from Executive Director (ED) Karen Nickolai. On 4/22/2026 the ED stated she is unable to locate R1s documentation in storage.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: ADM will submit a plan of correction to include how the facility will ensure residents records are retained for a minimum of 3 years following the termination of service to the resident. ED to submit POC by POC due date of 4/29/2026.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Karen Nickolai. LPA explained the purpose of the visit. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room. LPA randomly toured the following but not limited to bedrooms: residents bedrooms on both the first and second floor: 201, 203, 229, 231, 233, 235, 238, 236, 211, 213, 215, 216, 220, 219, 226, 209, 207, 232, 234, 107, 109, 111, 113, 115, 114, 117, 119, 120, 104, 101. There was no obstruction to block the walkways. The staff area of the facility was also inspected. LPA tested the delayed egresses in the facility. When tested the delayed egresses emitted a loud sound, which continued to ring until staff reset the alarm. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 114 degrees F in resident bathrooms. Fire extinguisher was serviced in April 16, 2025. The facility was equipped with smoke and carbon monoxide detectors. The Facility's Sprinkler System was last inspected on March 27, 2026. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on March 27, 2026. LPA reviewed facility disaster plan, which was last reviewed/updated on April 9, 2026. During todays visit, LPA requested a copy of the following residents death certificates (DR1-DR4). LPA also requested information regarding DR2-DR4's diagnosis. LPA reviewed facility records for 4 staff and 4 residents. LPA reviewed 4 resident medications and centrally stored medication records. LPA noted during medication audit/Review, that residents R1, R2 and R3 had medications that were not listed on the centrally stored medication record. Resident R1 did not have his/her medication M1 (fill date March 5, 2026) listed on his/her centrally stored medication record. Resident R2 did not have the following medications listed on his/her centrally stored medication record: M2 (fill date 3/4/2026), M3 (Fill date 11/11/2025), M4 (Fill date 12/24/2025), M5 (Fill date 12/24/2025). Resident R3 did not have the following medications listed on his/her centrally stored medication record: M6 (Expiration date October 2026), M7 (fill date 12/31/2025), M8 (Fill date 12/31/2025), M9 (fill date 3/28/2026) , M10 (Fill date 12/12/2025), & M11 (Fill date October 3, 2025). LPA showed the discrepancies to the health services director Kyleigh Whitely. No documentation was provided by health services director Kyleigh Whitely to LPA, to verify that the medications in question were included in each corresponding centrally stored medication record. A deficiency and technical violations are being cited during today's visit. This report was reviewed with Administrator Karen Nickolai and a copy of the signed report was provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Apr 9, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Karen Nickolai. LPA explained the purpose of the visit. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room. LPA randomly toured the following but not limited to bedrooms: residents bedrooms on both the first and second floor: 201, 203, 229, 231, 233, 235, 238, 236, 211, 213, 215, 216, 220, 219, 226, 209, 207, 232, 234, 107, 109, 111, 113, 115, 114, 117, 119, 120, 104, 101. There was no obstruction to block the walkways. The staff area of the facility was also inspected. LPA tested the delayed egresses in the facility. When tested the delayed egresses emitted a loud sound, which continued to ring until staff reset the alarm. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 114 degrees F in resident bathrooms. Fire extinguisher was serviced in April 16, 2025. The facility was equipped with smoke and carbon monoxide detectors. The Facility's Sprinkler System was last inspected on March 27, 2026. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on March 27, 2026. LPA reviewed facility disaster plan, which was last reviewed/updated on April 9, 2026. During todays visit, LPA requested a copy of the following residents death certificates (DR1-DR4). LPA also requested information regarding DR2-DR4's diagnosis. LPA reviewed facility records for 4 staff and 4 residents. LPA reviewed 4 resident medications and centrally stored medication records. LPA noted during medication audit/Review, that residents R1, R2 and R3 had medications that were not listed on the centrally stored medication record. Resident R1 did not have his/her medication M1 (fill date March 5, 2026) listed on his/her centrally stored medication record. Resident R2 did not have the following medications listed on his/her centrally stored medication record: M2 (fill date 3/4/2026), M3 (Fill date 11/11/2025), M4 (Fill date 12/24/2025), M5 (Fill date 12/24/2025). Resident R3 did not have the following medications listed on his/her centrally stored medication record: M6 (Expiration date October 2026), M7 (fill date 12/31/2025), M8 (Fill date 12/31/2025), M9 (fill date 3/28/2026) , M10 (Fill date 12/12/2025), & M11 (Fill date October 3, 2025). LPA showed the discrepancies to the health services director Kyleigh Whitely. No documentation was provided by health services director Kyleigh Whitely to LPA, to verify that the medications in question were included in each corresponding centrally stored medication record. A deficiency and technical violations are being cited during today's visit. This report was reviewed with Administrator Karen Nickolai and a copy of the signed report was provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Apr 9, 2026

Allegation investigated: Facility did not provide assistance with dressing in a timely manner. Facility did not provide food service.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Executive Director (ED) Karen Nickolai. On 10/21/2025, the Department received a complaint with the allegations that facility did not provide assistance with dressing in a timely manner and facility did not provide food service. On 10/30/2025, the Department conducted an initial investigation visit. LPA interviewed ED, 7 staff, and 4 residents. LPA observed all residents of the memory care unit were in activity room. Continue on lIC9099-C. Page 1 of 3. Unfounded Facility did not provide assistance with dressing in a timely manner: Facility did not provide food service: The allegations are that the facility did not provide assistance with addressing in a timely manner and facility did not provide food service. On 10/19/2025, RP alleged that food service of Memory Care Unit residents were not provided assists with dressing in a timely manner and their breakfast service were delayed. On 10/30/2025, LPA interviewed Executive Director (ED) Karen Nickolai. ED stated that on 10/19/2025, 3 caregivers and 1 medication technician in AM shift called out for work. There was only 1 caregiver who reported to work. There were 32 residents in care. ED stated he/she pulled 5 staff from food service and housekeeping service departments to assist residents with wake up dressing service and breakfast service. ED stated there were family members from 3 residents visited the facility on 10/19/2025 morning, they also assisted the residents with dressing service and breakfast service at that time period. ED stated residents were dressed up in the morning on 10/19/2025 and breakfast were served to residents, even though some delay for breakfast. On 10/30/2025, LPA interviewed Executive Cook (S1). S1 confirmed he/she and Maintenance Director (MD), 2 housekeepers, and a dishwasher were pulled to assist residents for wake up dressing service and breakfast service on 10/19/2025 morning. LPA interviewed 6 staff. 6 Out of 6 staff stated morning shift staff assist residents with their morning routine including dressing and breakfast services. 6 Out of 6 staff stated they did not hear any resident was left in the room without breakfast due to neglect. LPA interviewed 7 residents. 3 Out 7 residents stated they walk to dining room for meals and they do not have any complaints against the facility. 4 Out of 7 residents were unable to answer questions due to cognitive disorder. Continue on LIC9099-C. Page 2 of 3. Based on the interview, on 10/19/2025 morning, there were 3 caregivers and 1 medication technician called out for work, ED pulled 5 staff from housekeeping department and food service department to assist residents for dressing in the morning and breakfast service. The residents were assisted with dressing and were brought to dining room, and breakfast were served to residents on 10/19/2025. There is no evidence of neglect found on the incident of 10/19/2025 morning. The Department has investigated the above allegations. Based on the investigation, records reviewed, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citations noted at today’s compliant investigation visit. Exit interview was conducted with ED. This report was provided to review and for signature. A copy of this report was provided to ED.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 26-AS-20251021105638

Allegation investigated: Staff did not administer medication as prescribed.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced investigation visit to deliver complaint findings. LPA met with Executive Director (ED) Karen Nickolai. LPA stated the purpose of the visit. On 10/13/2025 the Department received a complaint with the above allegation. On 10/16/2025, the Department conducted a complaint investigation visit, and interviewed the Executive Director (ED), 5 Staff (S1 to S5) and 4 Residents (R1 to R4). LPA requested pertinent documentation to include but not limited to staff schedules, Medication Administration Records (MARs) and resident physician's reports. It has been alleged staff did not administer medication as prescribed sometime in October 2025. Page 1 of 2 Unfounded On 10/16/2025 and 1/28/2026 the Department interviewed Executive Director (ED). ED states she is not aware of staff not administering residents medications as prescribed at any time in October 2025. On 10/16/2025 the Department interviewed 6 Staff (S1 to S6). 4 Out of 6 staff state he/she administers resident's medications as prescribed. 4 Out 6 staff state he/she is not aware of staff not administering resident's medications as prescribed. S1 did not provide additional information. S4 states he/she does not assist with medications. On 10/16/2025 the Department interviewed 4 Residents (R1 to R4). 2 Out of 4 resident state he/she receives his/her medications. S3 state he/she does not need assistance with medication. S4 declined to be interviewed. The Department conducted a medication audit, reviewing 5 random resident's Medication Administration Records (MARs) and medication bottles with S2 and S3. A discrepancy was observed on 1 resident's MAR. A pill count was conducted, and the resident's medication bubble package was reviewed. The resident's medication was administered as prescribed, but it not was noted on the MAR. This agency has investigated the complaint alleging staff did not administer medication as prescribed. We have found that the complaint was UNFOUNDED meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. An exit interview was conducted with ED and a copy of this report was provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, Jan 28, 2026 · control 26-AS-20251013112243

Allegation investigated: Facility does not provide blankets for resident Facility does not make medical appointments to address resident's change in condition

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Karen Nickolai, Administrator (ADM). On 09/24/2025, the department received a complaint with the above allegations. On 09/25/2025, LPA Marrufo conducted an initial complaint investigation visit. On 11/06/2025, LPA Marrufo conducted an additional complaint investigation visit. Allegation: Facility does not provide blankets for resident - Unfounded When the department received the complaint, it was alleged that the facility was not providing a blanket for resident R1’s bed. See LIC9099-C pages for more information. Page 1 of 3. Unfounded During visit on 09/25/2025, LPA Marrufo observed R1’s bed and observed it to be covered with a bedsheet and a blanket along with an absorbent pad on the pillow and another absorbent pad on the bed. On 11/06/2025, LPA Marrufo obtained a copy of R1’s Admission Agreement. Section I.A.1.c states, “Furnishings. We encourage You to furnish your Apartment with your own furniture. If You are unable to provide your own furniture or You choose not to provide it, Ivy Park will provide You with furniture for an extra fee.” On 01/28/2026, LPA Marrufo obtained a copy of R1’s Optional Inventory of Personal Property. The line “I do not wish to inventory personal property” was initialed. During interview on 01/28/2026, R1’s Responsible Person stated that it was R1’s family’s responsibility to provide blankets for R1. During visit on 01/28/2026, LPA Marrufo interviewed staff S1-S3. Staff S1-S3 stated that family members of residents are responsible for providing blankets for their admitted family members. During visit on 01/28/2026, LPA Marrufo interviewed ADM. During interview, ADM stated families are responsible for providing blankets to their resident. Allegation: Facility does not make medical appointments to address resident's change in condition - Unfounded When the department received the complaint, it was alleged that the facility did not make medical appointments for R1 after R1 was observed to experience a change in condition that resulted in R1 having difficulty swallowing. During visit on 01/28/2026, LPA Marrufo obtained two Physician’s Reports for R1. One Physician’s Report was dated 02/10/2025 and indicated that R1 did have a special diet. R1’s second Physician’s Report, which was dated 02/14/2025, indicated that R1 did not have a special diet. Page 2 of 3. During visit on 11/06/2025, LPA Marrufo obtained Hospital Discharge Notes and Physician’s Fax Reports. A Hospital Discharge Note dated 06/19/2025 states, “Diet: Solids Soft & Bite-Sized…Liquids Mildly Thick…Medications crushed with puree...Supervision 1 to 1…Feed by: staff for patient safety” A Hospital Discharge Note dated 08/22/2025 states, “Diet: Regular soft and bite-sized with mildly thick liquids.” A Physician’s Fax Report that was sent by the facility to R1’s physician on 07/25/2025 states, “The above mentioned resident is on mechanical diet and crushing medications. We are updating our system and require periodic update. Please provide with signature otherwise please advise.” This agency has investigated the complaint allegations listed. Based on interviews, review of records, and observations, the department has found that the complaint allegations are unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. This report was reviewed with Administrator Karen Nikolai and a copy of this report was provided. Page 3 of 3. END REPORTthe state’s words, verbatim · CDSS document, Jan 28, 2026 · control 26-AS-20250924091243

Type of visit: Case Management - Other

Licensing Program Analyst Marcela Yanez conducted an unannounced case management visit to amend a complaint report. LPA met with Karen Nickolai, Exectutive Director. LPA announced the purpose of the visit. LPA amended a report LIC 9099C for substantiated allegation and LIC 9099C for unfounded allegation for a complaint 26-AS-20240923130821. No deficiency is cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Karen Nickolai, Administrator and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 31, 2025

Allegation investigated: Resident sustained multiple falls while in care due to lack of staff supervision Resident sustained multiple injuries while in care Facility is not kept free of pests Staff are not following resident's care plan Staff prevented resident in care from leaving facility common area Resident in care was not allowed to participate in activities Staff did not provide proper cleaning services to resident in care Staff did not ensure hot water was made available to residents in care Staff did not prevent residents from stealing other resident's personal items

On 12/30/25 Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced complaint investigation visit to deliver findings. LPA announced the purpose of the visit and met with Karen Nickolai, Administrator On 09/23/24 the department recieved a complaint with the above allegations On 09/26/24 LPA Kabarati conducted an initial complaint investigation visit and obtained pertinent documents. It was alleged that the facility did not prevent resident from falling on several occasions. Based on documentation 06/21/2024: No fall is noted. The fall nearest to the date of 06/21/2024 occurred on 06/18/2024. The fall was recorded/captured by the Safely You technology located in each of the residents room in the facility. R1 fell and hit his/her head and no injuries were noted and R1 denied any pain or discomfort. page 1 of 9 Unsubstantiated page 2 On 10/08/2025, staff S1 was interviewed. Based on interview, S1 stated that R1 had to wear dirty clothing because they were short staffed and the caregivers didn’t have enough time to get through all the laundry. S1 states that sometimes they couldn’t get through all the laundry, and all the residents’ dirty clothes would pile up. S1 stated that the caregivers tried their best but sometimes it wasn’t enough time to complete the laundry. On 10/08/2025, staff S2 was interviewed. Based on interview, S2 denied observing R1 wear dirty clothes. S2 stated that there were times when the resident’s dirty laundry piled up and knew it was an issue. S2 could not specifically recall R1’s laundry but stated that R1’s clothes were always changed if he/she got them dirty after a meal. Based on a photograph dated 09/20/2024. RP provided of R1’s clothing, it’s observed that R1’s black t-shirt contained white spots throughout his/her shirt and larger white spots on the left side of the chest area resembling food or drink droppings. R1’s black shorts also contained white spots throughout his/her shorts and larger spots on the left side on his/her upper thigh area resembling food or drink droppings. RP provided a second photo dated 09/22/24 that showed R1 to have food or drink droppings on the left side of black shirt and food or drink droppings on left side of black leggings. The Department has investigated the above allegations. Based on interview and observation the preponderance of evidence standard has been met; therefore, the above allegations are substantiated. Deficiency is cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Karen Nickolai, and a copy of the report and appeals rights was provided. page 2 “THIS REPORT WAS AMENDED. THE REPORT WAS INADVERTENTLY ATTACHED TO THE SUBSTANTIATED COMPLAINT FINDING. THE CONTENTS OF THIS PAGE BELONGS TO THE LIC9099-A FOR THE UNFOUNDED COMPLAINT ALLEGING “STAFF MISMANAGED RESIDENT’S MEDICATION. SEE LIC9099-A UNFOUNDED REPORT FOR MORE INFORMATION.” Based on record review, R1 was under hospice care. The medication (M1) was prescribed by the hospice care physician which the physician’s order instructions (dated 08/07/2024) stated “Administer … every 4 hours as needed for pain ….”. On 08/07/24 per facility observation R1 was prescribed a medication that was not in ALIS and RP was informed regarding medication not being administered due to not being in the system. RP gave the medication to R1. Per documentation all medication was given as directed by doctors orders. On 12/30/25 the department concluded its investigation. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiency is cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Karen Nickolai, Administrator and a copy of the report was provided. Page 2 “THIS REPORT WAS AMENDED TO REMOVE THE LINE “ALLEGING THAT THE FACILITY IS CHARGING SERVICES NOT AGREED ON THE ADMISSION AGREEMENT” AS THIS WAS INADVERTENTLY INCLUDED IN THE REPORT Based on record review, R1 was under hospice care. The medication (M1) was prescribed by the hospice care physician which the physician’s order instructions (dated 08/07/2024) stated “Administer … every 4 hours as needed for pain ….”. On 08/07/24 per facility observation R1 was prescribed a medication that was not in ALIS and RP was informed regarding medication not being administered due to not being in the system. RP gave the medication to R1. This department has investigated the complaint. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiency is cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Karen Nickolai, and a copy of the report was provided. Page 2 On 07/16/2024 R1 had an unwitnessed fall and in the hallway R1 was walking and lost his/her balance resident returned to community with no injuries. On 07/17/2024 R1 fell the fall was recorded/captured by the Safely You technology and RP denied any pain or discomfort and no injuries were noted. On 08/05/24 R1 was observed laying on his/her back on the bathroom floor when asked R1 stated he/she had fell. R1 complained of back and head pain. R1 was sent to the hospital for follow up and was given an appointment for follow up with neurosurgery. On 08/06/2024, R1 was discharged back to the facility with a final diagnosis listed a brain bleed. On 09/12/24 the facility observations stated resident was a fall risk. ED was asked if a resident sustaining over 22 falls was normal and ED stated that approximately two to four weeks prior to R1 being moved out of the facility, facility staff “suggested” to R1s family that the facility could no longer provide care for R1. Facility staff suggested that R1 have one-on-one supervision, be placed in a different setting, or have his/her medications changed. RP initiated R1s moving out of the facility because ED “asked RP to provide one on one.” At the time that R1 lived in the facility, the facility was not understaffed. There were only 25 residents in the facility when R1 lived in the facility. R1s care plan stated staff were scheduled to do wellness checks every 3 hours to check for safety and any needs as well as to see if resident is asleep and or having any needs. R1 was also on bowel monitoring 3 times a day. R1 moved into the facility on 05/25/24. R1 fell on 05/28/24 R1 had a witnessed fall in the activity room, no injury noted and denied pain and discomfort. On 05/31/24 R1 had restlessness and agitation R1 repeatedly looking for exit seeking behavior facility staff redirected the resident away from all exit doors. R1 was noted to be awake and confused and refused to go inside his/her room, it was noted for noc shift to do frequent checks. It was alleged Resident sustained multiple injuries while in care. On 06/18/24 R1 was standing by the refrigerator and had a fall and lost his/her balance and hit his/her head no injuries noted Page 3 On 06/18/24 facility staff Director of Nursing published a care plan and updated environmental and lighting for R1 and staff training on placement of assisted devices and to remind R1 to use assistive devices. Care plan was also updated on provided accompanied walks for resident for daily shifts. Based on record review the resident had a record of unsteady gate, history of witnessed and unwitnessed falls. RP submitted photo dated 06/25/24 which showed a bruise on left hip, left elbow and another bruise on left shoulder blade. On 07/16/24 resident had a fall and went to the hospital and suffered a hip contusion, head injury and cervical strain. On 07/17/24 R1 was noted for fall risk and under monitoring on facility observations. RP submitted photo dated 09/20/24 with a small scratch on R1s left side of eye under eyebrow about 1 inch in length Based on record review and interview R1 was reminded to use walker to ambulate and or use a 4 point cane. R1 was also monitored by staff and reminded to stop during walks when he/she felt weak or unstable. It was alleged that the facility is not kept free of pests as the reporting party reported observations of ants seen in R1’s bathroom, refrigerator and linens. Based on 2 staff interviews, it was stated that the facility has problems with ants in the community. Both staff stated that when they observe ants, they are treated with ant spray. The Executive Director stated that the facility has pest control services which serve the entire facility once a month and conducts routine services. The executive director stated to be unsure if there were any ant problems inside R1’s bedroom. On 05/21/2025, LPA Kabariti conducted an unannounced visit and entered rooms #232, 234, 236, 238, 237, 233, 229, 202, 201, 207, and 213. LPA Kabariti did not observe ants inside the resident bedrooms. On 10/08/2025, LPA Kabariti conducted another unannounced visit and entered rooms 207, 233, 234, and 211. LPA Kabariti did not observe any ants inside the residents’ bedrooms. Page 3 It was alleged that the facility is not following R1’s care plan as the staff began to miss the resident’s shower days, which was scheduled for Monday and Fridays. The reporting party (RP) stated that he/she typically visits R1 every evening, however, missed four days of visits due to health issues. Per care plan RP states that R1 was under hospice, and hospice began bathing R1 but was never consistent. RP stated that per the granny cam that RP installed inside R1’s bedroom, it showed staff taking R1 to the restroom and immediately taking R1 to breakfast. RP stated that once Hospice services were initiated the facility did not provide any showers to R1. RP stated that Hospice caregiver would give showers to R1 3 times a week and the other 2 days were supposed to be given by Facility Staff. RP stated he/she volunteered to give R1 showers when he/she visited. RP stated that the videos from granny cam of facility not providing care to R1 were deleted by spouse. RP did mention that other residents were observed in the videos eating residents food and frequently entering and exiting R1s room but was unable to provide videos because they were deleted. On 05/21/2025, the Executive Director (ED) was interviewed. Based on interview, the ED stated that R1’s shower days were typically twice a week unless it’s requested by responsible party to have R1 shower more or less days. The ED denied R1 missing his/her shower days and did not remember if R1 refused any showers. On 10/08/2025, staff (S1) was interviewed. Based on interview, S1 stated that there were times in the morning when they were short staffed and were not able to give all the resident showers but knew that each staff tried to help each other out. S1 could not recall the exact dates, whether R1 ever missed his/her shower days when they were short staffed, and did not recall R1 refusing any showers. page 4 On 10/08/2025, staff (S2) was interviewed. Based on interview, S2 stated that R1’s showers were 2-3 times a week in the morning time. S2 stated to have assisted R1 with showers once and did not recall any issues when showering R1. S2 stated they all worked together to get all the residents showered. If the staff didn’t have time in the AM, they always communicated to the PM shift and PM shift helped. S2 denied any residents missing their shower schedule days, to include R1. R1s care plan showed R1s scheduled days to shower was Monday and Fridays in the morning. RP stated that the Hospice caregiver was supposed to shower R1 3 times a week and facility staff were supposed to shower R1 2 times a week. Based on record review, the facility does not have any record logging the completion of resident’s showers. RP stated that Suncrest hospice services was not providing showers to resident and switched to Redwood Hospice services due to the lack of care Suncrest hospice care was providing. RP stated that R1 was to receive 3 showers a week and in the interim the facility staff was to give R1 a shower on days the hospice caregiver did not provide showers. RP stated R1 did not receive showers on the other 2 days of the week. RP stated he/she would give showers during his/her visit. S1 stated that the facility was short staffed and sometimes R1 did not receive a shower from facility staff. Page 5 It was alleged that the facility staff blocks the common area with a wooden round table so R1 cannot leave on his/her wheelchair. On 09/29/2025, the Executive Director (ED) was interviewed. Based on interview, the ED denied observing R1 blocked by the wooden round table and unable to leave his/her wheelchair. On 10/08/2025, staff (S1) was interviewed. Based on interview, S1 stated that R1 needed 1:1 care and would normally have a caregiver sit with R1 in the common area. S1 stated one time where he/she saw R1 sitting on his/her wheelchair in front of a table with the wall behind R1, so R1 couldn’t stand up. S1 stated that R1 was in the wheelchair all the time but R1 always tried to stand up. S1 stated that R1 had a lot of falls. S1 stated the staff positioned R1 in between the wall and table to prevent R1 from falling and for safety reasons. S1 states that the Executive Director (at the time) knew about it and stated it was for safety. S1 states that because the ED knew about it and didn’t say anything, S1 just followed. On 10/08/2025, staff (S2) was interviewed. Based on interviews, S2 stated that when R1 participated in activities, staff would always sit with R1 for safety reasons because R1 was a fall risk. S2 stated that R1 would be placed in a position where R1 can move freely. S2 denied the observation of R1’s movement being restricted from being placed in between the wall and table. S2 stated that if the staff ever had challenges with R1, they would always help each other. On 05/21/2025, 5 staff were interviewed who all denied observing staff to prevent a resident from leaving the common area. Staff stated that residents can wander throughout the hallway with staff supervision. On 05/21/2025 and 10/08/2025, LPA Kabariti conducted an unannounced visit and did not observe any residents who were blocked in the common area with a wooden round table. LPA Kabariti observed residents participating in activities in the common area and some residents were observed walking through the hallways. Page 6 It was alleged that the staff do not allow the resident to participate in activities. Based on the reporting party (RP), it was stated that R1 is left in the common area to watch TV with other residents for hours at a time. RP stated that R1 is not allowed to participate in activities because R1 is unable to walk/stand. On 09/29/2025, the Executive Director (ED) was interviewed. Based on interviews, the ED stated that R1 was always allowed to participate in activities. ED stated that R1 was always in the common areas because the staff needed to keep a close eye on R1 due being a fall risk. ED stated that R1 would participate in activities when they put sensory items on the table in the activity room. On 09/29/2025, 5 staff were interviewed who all stated that all residents can participate in activities. On 10/08/2025, staff (S1) was interviewed. Based on interviews, S1 stated that R1 participates in all activities. S1 stated that R1 is normally in the common area with his/her 1:1 staff participating in activities. On 10/08/2025, staff (S2) was interviewed. Based on interviews, S2 stated that R1 always participated in activities. S2 stated that R1 participated in arts and crafts, music, and the performances. It was alleged that the staff did not provide proper cleaning services to residents in care. Based on the reporting party (RP), it was stated that R1’s bedroom had not been clean the entire time R1 has been at the facility until R1’s responsible party had complained in August 2024. It was stated that the next day, the Executive Director had R1’s room cleaned. It was stated that since the first cleaning in August, the room had been vacuumed one more time in September 2024, the toilet and shower have only been cleaned twice, and the trash inside R1’s bedroom was not taken out nightly. RP was unable to provide any photographs of room that not being cleaned and or garbage not being removed and full. During a local law enforcement welfare check on R1 on 09/26/2024, it was noted that R1’s room was observed clean. Page 7 On 05/21/2025, the Executive Director was interviewed. Based on interview, the ED stated that full housekeeping is completed once a week which they consider as the “deep clean” which entails beddings, deep clean the restroom, entire room, refrigerator, and counter. The ED stated that the trash is taken out daily and throughout the shift. On 05/21/2025, 5 staff members were interviewed. It was stated that housekeeping is completed daily and the caregivers help with to maintain the cleanliness of the bedrooms. Staff stated that the residents’ trash are taken out in the morning. On 10/08/2025, staff (S1) was interviewed. Based on interview, S1 stated that because of the short staff at the time of R1’s stay at the facility the rooms were not cleaned well. It was stated that the caregivers were supposed to throw out the trash every shift or when the resident’s trash bin was full but there were times when the trash was full because they were short staffed. It was stated that they did have housekeeping staff but when the housekeepers were off, it would be the caregiver’s responsibility to maintain the resident rooms. On 10/08/2025, staff (S2) was interviewed. Based on interview, S2 stated that there were times when the residents’ trash bins did accumulate and were full. S2 stated to think the trash wasn’t taken out timely because the caregivers would forget or would be too busy. On 05/21/2025, LPA Kabariti conducted an unannounced visit and randomly entered 11 resident bedrooms between the time 09:30AM – 10:30AM. 1 out of 11 resident bedrooms had a full trash bin but the room was observed well maintained. The ED stated that the staff may still not be done taking out the trash. All remainder of the resident bedrooms that were randomly entered were observed well maintained. Page 8 On 10/08/2025, LPA Kabariti conducted another unannounced visit and randomly entered 6 resident bedrooms. LPA Kabariti observed that 1 out of 6 resident bedrooms was not well maintained. LPA observed tissue paper scattered through the floor and brown spots throughout the carpeted floor and wood floor, a foul order in the resident’s bedroom, and a body wash bottle that contained a brown substance smeared at the top of the bottle. The Executive Director immediately called the housekeeper for assistance to clean the resident’s bedroom It was alleged that the facility did not have hot water available for residents for two days. On 05/21/2025, the Executive Director (ED) was interviewed. Based on interview, ED stated that there was a time when there was issue with R1’s hot water. S1 states the hot water was fixed immediately and the issue only lasted a couple days. ED states the facility has issues with the hot water temperature and was reported to her on 05/19/2025. ED states they have a quote to repair on the issue. ED states in the meantime, they are utilizing empty apartments with hot water for showers. On 10/08/2025, staff (S1) was interviewed. Based on staff interview, it was stated that some rooms did not have hot water, and it was months until some of the rooms hot water was fixed. S1 states that when they didn’t have hot water, the staff would borrow the empty rooms to shower the residents. S2 stated issues with some of the residents’ hot water not working in their bedrooms. S2 stated that if a resident’s hot water wasn’t working, they’ll warm up water and give the resident a bed bath, or a sponge bath, or take the resident to another room with working hot water. It was alleged the staff did not prevent residents from stealing other residents personal items. On 10/08/25 S8 stated all the rooms had a code to get into the rooms because there were concerns that some of the residents would go into other residents’ rooms. Since he/she started working there, all the bedrooms were always locked from the outside where they required a code to get in. Page 9 3 out of 6 staff stated he/she observed residents wandering into other residents’ rooms, he/she would help guide them in another direction. If he/she observes items that were accidentally misplaced, he/she take it back to whoever they belonged to. 3 out of 6 staff stated if they would see a resident stealing something he/she would make sure to redirect the resident verbally. Then the staff would take the items back to the resident room. On 12/30/25 the department has concluded its investigation. Based on documents reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. No deficiency is cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Karen Nickolai, and a copy of the report was provided. End of Reportthe state’s words, verbatim · CDSS document, Dec 30, 2025 · control 26-AS-20240923130821

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jan 9, 2026

87464(f)(4) 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... activities of daily living such as dressing, eating, bathing and assistance... this requirement was not met as evidenced by: Based on interview and photo, S1, S2 stated the facility was short staffed and the R1s laundry did not get washed. S1 stated R1 had to wear dirty clothing. RP provided photo R1 had soiled clothing on two seperate occasions 09/20/24, and 09/22/24. This posed a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Dec 30, 2025

Plan of correction: Administrator stated she will provide a letter of understanding of regulation and has hired more staff. ADM will submit to LPA Yanez by POC due date 01/09/25 via email.

Allegation investigated: Staff did not seek timely medical care for resident in care Staff did not attend to resident in care in a timely manner

Licensing Program Analyst (LPA) Marcela Yanez arrived unannounced to deliver the finding for the above allegations and met with Jessica Pryor, Regional Operations Specialist (ROS). On 09/23/24, the Department received the complaint. On 09/26/24, the initial complaint investigation was conducted. The following documents were obtained for this investigation to include the resident roster, staff schedule, 3 resident’s physician’s report, care plan, progress notes, face sheet, centrally stored medication record, medication administration record, resident (R1)’s medical records, and police report. It was alleged that the staff did not seek timely medical care and did not attend to resident (R1) care in a timely manner when R1 had a fall on 08/05/24. Page 1 of 4 Substantiated Page 2 of 4 Based on interview with reporting party (RP). RP stated that R1 fell in the bathroom on 08/05/24 at approximately 0400 hrs. and screamed for help for 3 hours until someone (a facility staff) found R1 at 0730 hrs. and called 911. Based on the investigation, R1 sustained an unwitnessed fall and was found by facility staff at approximately 0700 hours. R1 was admitted to the hospital by ambulance at approximately 0740 hours. On 08/06/24, R1 was discharged back to the facility with a diagnosis of an acute brain bleed and was placed on hospice care on 08/05/24. The facility is equipped with a fall monitoring system set up in each resident’s room in the facility, however, there were no notes indicating the monitoring system caught R1’s fall on 08/05/24. Based on interviews with 2 witnesses (W1 and W2), W1 reported that he/she received a phone call from the facility staff at approximately 0730 hours on 08/05/24. Staff reported to W1 that R1 fell and was sent to the hospital. W2 stated, upon notification of R1s fall, they watched a video recording of R1’s room. The video recording was from a personal camera installed in R1s room by W1 and W2 and facility granted permission for the camera. The purpose was to remotely monitor and keep an eye on R1. The camera captured movement and sound made by R1 but there was no visual captured from the bathroom. Page 3 of 4 W2 stated the following series of events.The camera detected the motion caused by R1 and recorded R1 getting out of bed at approximately 0400 to 0430 hours and entering the bathroom. W2 heard when R1 fell in the bathroom. R1 fell at approximately 0400 hours, afterwards can be heard screaming for help for two to three and a half hours before a staff came and assisted R1 at 0730 hours. There was no visual capturing R1s fall in the bathroom but could be heard in the background screaming for help. Based on interviews with 4 staff (S1 to S4). S1 stated that on 08/05/24, his/her shift started at approximately 0600 hours and was present. When S1 was asked how three hours could have passed between the time that R1 fell and when R1 was found by facility staff, S1 stated that it was because “someone was not caring for R1.” S2 stated, on 08/05/24 a caregiver (name unknown) reported to S2 that R1 fell and was not assisted for three to four hours. S2 stated one caregiver and one med tech at night are scheduled to assist all residents. S2 stated that it was possible that R1 had fallen and waited three to four hours because a care giver may not check on residents often enough. S3 stated, on 08/05/24, his/her shift started at approximately 0630 hrs. S3 was alerted by care staff that R1 had fallen. S3 entered R1s bathroom but does not know how long R1 was on the floor waiting for staff assistance because no one told him/her. S3 stated safety checks are supposed to be conducted every one to two hours at night, however, checks are not documented. Page 4 of 4 S4 stated R1 was under hospice care. (note: Hospice Care for R1 was initiated after the incident of 08/05/24). S4 stated facility will call hospice to assess R1 before calling 911. S4 stated the facility is equipped with a system called Safely You, which monitors residents’ rooms and alerts facility staff when a fall is detected. S4 was asked how R1 fell on 08/05/24, S4 stated he/she has no recollection of the incident. When asked the length of time R1 had to wait for staff assistance, S4 stated that it was possible that R1 fell and left unattended for three hours because there could have been an emergency involving another resident that would have caused facility staff to not check on R1 for three hours. Based on review of R1s medical record and facility observation notes, R1 is a fall risk and has sustained multiple unwitnessed falls and R1 requires increased supervision and assistance, R1 is diagnosed with dementia and has a high fall risk. R1 has 30 documented witnessed and unwitnessed falls between 05/25/24 and 09/24/24. A majority of the falls were “witnessed” by the facility’s monitoring system, however on 08/05/24, R1 sustained an unwitnessed fall and no time stamp to indicate R1s fall. R1s care plan includes daily checks from 10:30 a.m. to 9:00 p.m. 4x, from 11:00 p.m. to 4:00 a.m. 3x and from 7:00 a.m. to 8:30 p.m. 4x. No documentation if wellness check were conducted. Based on observations, interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Citations are issued based on the California Code of Regulations (CCR) Title 22, Division 6, Chapter 8 for Additional Personal Rights of Residents in Privately Operated Facilities and Incidental Medical and Dental Care are cited on the attached LIC 9099D. An exit interview was conducted with Jessica Pryor Regional Operations Specialist, a copy of the report and appeals rights were providedthe state’s words, verbatim · CDSS document, Aug 27, 2025 · control 26-AS-20240923130821

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Aug 28, 2025

87465(g) Incidental Medical and Dental Care: (g)The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including…apparent life-threatening medical crisis…This requirement is not met as evidenced by: Based on interview and record review, facility staff did not seek timely medical care for R1. On 08/05/24 R1s were recorded calling for help from 0400 to 0730 hrs. Staff were recorded coming into the R1s room at 0730 hrs. and 911 was called. S3 stated he/she was alertedthe state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: The ROS stated that the facility will conduct In-Service training with staff on wellness checks and will provide proof of training by POC due date 08/28/25 *cont'd: by staff when his/her shift started at approximately 0630 hrs. S4 stated R1 probably waited for four hours to get help because staff is probably attending to another resident emergency need. Which pose/poses an immediate health, safety and personal-rights risk to person in care

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 28, 2025

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities…shall have all the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff… This requirement is not met as evidenced by: Based on interview staff did not provide care to R1 in a timely manner. On 08/05/24, R1 was recorded screaming for help from 0400 to 0730 hrs. S1 stated R1 waited for hours because “someone is not caring for R1.” S2 stated R1 was possibly waiting for hours to be helpedthe state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: The ROS stated that the facillity will conduct In-Service training for staff to ensure residents rights are protected by POC due date 08/28/25 *cont'd :because there are 2 staff for all residents at the time of the incident. S3 stated he/she was alerted by staff when S3 arrived at 0630 hrs. that R1 had fallen in the bathroom. Which pose/poses an immediate health, safety and personal risk to person in care.

Type of visit: POC

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Plan of Correction (POC) visit for deficiencies issued on 7/8/2025. LPA met with Regional Operations Specialist Jessica Pryor. LPA stated the purpose of the visit. On 7/8/2025, during a Complaint Investigation visit for Complaint 26-AS-20241024102358, LPAs Monter and Tarin conducted a random audit of 4 Residents medications. During audit, LPAs observed medication discrepancies for R8. A POC was developed with the facility. The POC was submitted by POC due date of 7/9/2025. During today's visit, LPA Tarin reviewed staff medication training on 7/11/2025, to include topics such as medication administration, A Letter of Deficiencies Citations Cleared provided during visit. No deficiencies cited during this visit per California Code of Regulations, Title 22. An exit interview was conducted with Regional Operations Specialist Jessica Pryor and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 17, 2025

Allegation investigated: Staff are mismanaging resident's medication

On 10/24/2024 the Department received a complaint with the above allegation. On 10/31/2024 LPAs conducted the initial 10-day investigation. On 10/31/2024 LPAs Monter and Fortes audited medications for R1 to R3. During audit of R3’s medications, Medication M1 had a bubble pack that contained medication logded between the plastic and was not administered. Based on review of R1’s Medication Administration Record (MAR), the medication in the bubble pack (listed as #28 in the MAR), was listed as ‘administered.’ Review of the MAR, LPAs observed R1 did not receive medication M1. Page 1 of 2 Substantiated Based on review of R1’s physicians report dated 8/9/2024, R1 is unable to administer his/her own medications. On 10/25/2024 LPA Christine Dolores received a voicemail and email from S1 to self-report medication errors. LPA Dolores spoke with S1 who stated the facility was reporting medication errors for 2 residents. S1 stated a plan of correction was being conducted with nurses and medtechs. On 7/8/2025 LPAs Monter and Tarin conducted a random audit of 4 Residents. During audit, LPAs observed medication discrepancies for R8. LPAs observed Medication M1, which states “Take 1 tab by mouth in the morning, before breakfast.” LPAs reviewed Medication M1’s bubble pack and observed the tablet on #8 was still inside the bubble pack. The bubble pack states the medication was opened on 7/1/2025. A review of R8’s Medication Administration Record (MAR) states that R8 was administered M1 from 7/1/2025 to 7/8/2025 at 6:00AM. Based on review of R8’s physicians report dated 12/20/2023, R8 is unable to administer his/her own medications. LPAs interviewed Health Services Director (HSD). HSD stated she was not informed of any refusal by staff. LPAs asked if HSD could explain what occurred. HSD stated, “I don’t know.” During audit of residents R7 to R10, LPAs noted that each resident has medications that were not listed on the Centrally Stored Medication log. LPAs interviewed Health Services Director (HSD). HSD stated “I don’t know. Maybe the med-techs didn’t central log it.” HSD did not provide additional information. Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations (Title 22), are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 8, 2025 · control 26-AS-20241024102358

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jul 9, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be...competent to provide the services necessary to meet resident needs This requirement was not met as evidenced by Based on investigation, R8 requires assistance with medication administration. Resident medication M1 was not administered on 7/8/2025. HSD stated "I don't know" regarding the discrepancy, which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: Licensee states the facility will conduct additional medication administration training by 7/15/2025. Licensee will submit the Plan of Correction (POC) by POC due date 7/9/2025, and submit completion of training to the Department.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6)(A-F) · Plan of correction due date: Jul 15, 2025

87465 Incidental Medical and Dental Care (h)(6)(A-F) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year... This requirement was not met as evidenced by Based on investigation, R7 to R10, LPAs noted that each resident has medications that were not listed on the Centrally Stored Medication log. HSD stated, "I don't know" regarding the discrepancies, which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: Licensee states the facility will conduct additional medication administration training by 7/15/2025. Licensee will submit the Plan of Correction (POC) by POC due date 7/9/2025, and submit completion of training to the Department

Allegation investigated: Facility did not ensure sufficient number of staff at all times to provide the services necessary to meet the resident's needs. Staff are not trained in assisting residents with medication.

On 10/24/2024 the Department received a complaint with the above allegations. On 10/31/2024 LPAs conducted the initial 10-day investigation. On 10/31/2024 LPAs interviewed 2 staff. 2 Out of 2 Staff state the facility has enough staff to provide the services necessary to meet resident’s needs. On 7/8/2025 LPAs interviewed 4 staff. 4 out of 4 staff state the facility has enough staff to meet residents’ needs. Health Services Director (HSD) states the facility has enough staff to meet residents' needs. On 7/8/2025, LPAs interviewed 7 Residents. 4 Out of 7 Residents stated the facility has enough staff to provide the services necessary to meet the residents’ needs. 3 Out of 7 residents were unable to provide an answer to LPAs questions. Page 1 of 2. Unsubstantiated On 10/31/2024 LPAs interviewed 2 Staff. 2 Out of 2 Staff stated he/she has received training in medication administration. On 7/8/2025, LPAs interviewed 4 staff. 3 Out of 4 staff stated he/she does not assist residents with medications, as he/she is not a med-tech. S3 states he/she has received training in assisting residents with medications. LPAs reviewed 4 med-tech staff training records. Based on review, 4 Out of 4 med-techs have completed training. LPAs interviewed 7 Residents. 4 out of 7 Residents stated he/she receives assistance with medications. 3 Residents were unable to provide an answer to LPAs questions. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 8, 2025 · control 26-AS-20241024102358

Allegation investigated: Facility Staff did not complete their required training Hazardous items are accessible to residents in care.

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Regional Operations Specialist Krystal Jenkins. On June 17, 2025, the Department received a complaint alleging Facility Staff did not complete their required training. On June 23, 2025, LPA Manuel Monter interviewed Staff S1-S4. All staff members interviewed stated they have received their required 40 hours of initial training. Page 1 Out of 3 Unfounded On July 8, 2025, LPA Manuel Monter interviewed Staff S5-S6. Both staff interviewed stated they have completed their 40 hours of initial training. LPA interviewed Health Services Director (HSD). HSD stated the facility staff are provided their required training. The Department randomly reviewed 6 staff members training records. All training records reviewed are complete. No discrepancies noted. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Hazardous items are accessible to residents in care. On June 17, 2025, the Department received a complaint alleging Hazardous items are accessible to residents in care. On June 23, 2025, LPA Monter interviewed staff S1-S4. All staff interviewed stated they have not seen any detergents, bleaches or other potentially harmful materials accessible to residents in care. LPA interviewed Regional Operations Specialist (ROS), Jessica Pryor. ROS stated the facility doesn’t have toxics/detergents or other dangerous items accessible to residents in care. Licensing Program Analyst Manuel Monter toured the facility during the complaint investigation. LPA toured the following areas: dining area, activity area and hallways. LPA toured all residents’ bedrooms that were currently in use. This included the following bedrooms: 229, 233, 237, 238, 214, 220, 222, 226, 228, 225, 218, 217, 215, 213, 203, 201, 202, 234, 232. LPA did not observe any toxics, detergents or other potentially harmful materials accessible to residents in care. On July 8, 2025, LPA Manuel Monter interviewed Staff S5-S6. Both staff interviewed stated they have not observed dangerous or toxic items accessible to residents in care. LPA interviewed Health Services Director (HSD). HSD stated the facility staff ensure toxic materials LPA's interviewed residents R1-R7. Residents R1-R6 stated they have not observed any toxic materials, detergents, or bleach accessible to residents in care. Resident R7 was unable to provide response to questions LPA's posed. Licensing Program Analyst Manuel Monter toured the facility during the complaint investigation. LPA Monter and Tarin toured the facility common areas and resident bedrooms. LPAs did not observe any toxic materials, detergents or bleach accessible to residents in care. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. On July 8, 2025, LPA Manuel Monter interviewed Staff S5-S6. Both staff interviewed stated they know when a resident needs assistance with eating. Both staff interviewed stated staff will assist residents with eating. Both staff interviewed stated they have not observed facility staff not assist a resident who needed assistance with eating. LPA interviewed Health Services Director (HSD). HSD staff know to assist residents who need assistance with feeding. HSD stated staff will assist residents who haven't eaten their food and help guide them with eating. HSD stated facility staff do not neglect residents who need assistance with feeding. LPA's interviewed residents R1-R7. Residents R1-R6 stated they do not need assistance with eating and have no issues. R1-R6 stated staff will provide assistance if they ask. Resident R7 was unable to provide response to questions LPA's posed. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 2 Out of 2.the state’s words, verbatim · CDSS document, Jul 8, 2025 · control 26-AS-20250617095450

Allegation investigated: Staff are not implementing proper infection control practices at the facility Staff did not provide adequate laundry services to residents in care Staff did not provide good quality foods to residents in care Residents sustained multiple falls due to insufficient staff at the facility Staff did not order resident's medication in a timely manner

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Regional Operations Specialist Krystal Jenkins. On January 27, 2025, the Department received a complaint alleging Staff are not implementing proper infection control practices at the facility / Staff did not provide good quality foods to residents in care. It has also been alleged the food was contaminated. Page 1 Out of 6. Unsubstantiated On January 31, 2025, LPA Simi Rai interviewed Executive Director (ED) Kenia Padilla. ED stated there was a Norovirus outbreak 2 weeks ago. ED stated the initial case was on 1/13/2025. The visitors were notified with posters at the front and throughout the building. ED stated there were 4 residents with positive Norovirus and everyone went into isolation. ED stated the Maintenance Director maintained a log for sanitization. ED stated she informed the Department of Health Services and they advised her to close the dining room. ED stated each resident would have a 3-drawer cart and each cart would have PPE supplies such as N95/masks, eye safety glasses, shoe covers, gloves, hand scantier, and gowns. ED stated the staff would prepare the meals in the kitchen, place food in individual containers and give each resident their food in their rooms. ED stated she knows the staff were following food service sanitation practices because she was on the floor as well, serving the food to the residents. ED stated last week, they started to bring residents into the dining room which needed assistance with feeding and place them 6 feet apart. LPA Rai made the following observations during the complaint investigation visit. LPA Rai observed the kitchen area. LPA Rai observed the kitchen prep area, the dishwasher area, pantry and refrigerator/freezer. All areas were clean and clear of dust and debris. LPA Rai observed the laundry room. LPA Rai observed 3 washers, and 2 dryers. One dryer was out of service, but it going to be repaired. LPA Rai observed two resident rooms Room 213 and 103 which stored PPE supplies. LPA Rai observed boxes of gloves, masks, gowns, sanitizing wipes and trash cans with lids. On July 8, 2025, LPA Manuel Monter interviewed residents R1-R7. R6 and R7 residents interviewed were unable to provide answers to questions LPA's posed. Residents R1-R5 stated they don't know what the facility did when there was an outbreak and have no knowledge. LPA Manuel Monter and Marcella Tarin interviewed staff S1-S4. All staff interviewed stated the facility follows infection control protocols when there is an outbreak. All staff interviewed stated facility staff wear gloves and dispose of them when they are finished providing care inside a residents bedroom. LPA interviewed Health Services Director (HSD). HSD stated the facility is following there infection control protocols. HSD stated kitchen staff do not provide care giving services to residents. HSD stated kitchen staff follow infection control protocols. HSD stated when there is an outbreak, the facility will deliver meals to residents apartments and provide disposable dinning wear. Page 2 Out of 6. On July 8, 2025, LPA Manuel Monter PPE supplies, which included, but not limited to: gloves, masks, gowns. Based on a review of facility Receipts, the facility does have documentation showing they have bought PPE in November 2024, December 2024 and January 2025. The Department reviewed staff training documents from November 2024, December 2024, January 2025 : Falls and fractures, Residents ADL’s, PPE use, Hand Hygiene, Fall prevention, GI Virus/Infection Control & an In-Service food safety and preventing Cross contamination. Based of facility documentation, the facility had a Sanitation log of common areas. This included Door knobs, chairs, tables, elevators, buttons, floors and restrooms. Furthermore, the log begins in January 6, 2025- January 31, 2025. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Residents sustained multiple falls due to insufficient staff at the facility On January 27, 2025, the Department received a complaint alleging residents sustained multiple falls due to insufficient staff at the facility On January 31, 2025, LPA Simi Rai interviewed Executive Director (ED) Kenia Padilla. ED stated some families are confused and they think they provided 1:1 care giving, but they don't. ED stated their staff do not break the fall, the caregivers will support the resident afterwards. LPA Rai made the following observations: LPA Rai observed 12 residents and 3 staff (1 activity person and 2 agency staff). Page 3 Out of 6. On July 8, 2025, LPA Manuel Monter interviewed residents R1-R7. Residents R1-R4 stated they have no issues or concerns regarding staffing. Residents R5-R6 stated they don't know about any staffing issues and have no knowledge. Residents R7 was unable to provide LPA with any response to questions posed. LPA Monter interviewed staff S1-S4. All staff interviewed stated there is no resident in the facility that requires 1:1 staffing. All staff interviewed stated there is sufficient staff to meet the needs of the residents. LPA Monter interviewed Health Services Director (HSD). HSD stated the facility has sufficient staffing to meet the needs of residents. On June 23, 2025 and July 8, 2025, LPA toured the facility inside and out. LPA toured the common areas and resident bedrooms. LPA did not observe the facility in disrepair or unclean. While touring the facility LPA did not observe any resident in a soiled or disheveled state. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Staff did not order resident's medication in a timely manner On January 27, 2025, the Department received a complaint alleging Staff did not order resident's medication in a timely manner On January 31, 2025, LPA Simi Rai interviewed Executive Director (ED) Kenia Padilla. ED stated the facility staff are responsible for refilling the medication for the residents. They either use Kaiser and/or Pharmerica. ED stated there was one particular family where there was an issue with refilling the medication on time and the Wellness Director can talk more about it. Ed stated the pharmacy is either delaying the delivery of the medication or lying about not delivering the medications at the facility. Page 4 Out of 6. LPA Rai interviewed Wellness Director (WD) Carmen. WD stated they will send the medication order to the pharmacy (Pharmerica) and they let the resident's family and PCP know about the delay. W1 stated they let the doctor know by phone call or fax. W1 stated the issues comes in the place when the resident's medications order is done with refills, and the pharmacy needs to get new orders from the doctor and that causes a delay. W1 stated they have discussed this issue with the pharmacy regional office and their facility's regional office. W1 stated the residents that have issues with refills are R1 and R2. W1 stated if there are 7-10 pills left in the medication, they will notify the pharmacy for refill. But the pharmacy will delay the delivery. W1 stated the pharmacy will say the medication is en-route to be delivered but they do not deliver the medications to the facility. W1 stated the pharmacy does not tell the facility that they have not received the doctor's orders. W1 stated if the pharmacy tells them the pending physician order status, then they can call the family to obtain physician's orders for the medications. For medication's they will ask the family to get through to the doctor to ask the doctor to sign the new prescription order for the refill of medication. On July 8, 2025, LPA Manuel Monter interviewed residents R1-R7. Residents R1-R6 stated they have been getting their medications. Residents R1-R6 stated they have no concerns when it comes to their medications. Resident R7 was unable to provide LPA a response when asked. LPA Monter interviewed staff S1-S4. All staff interviewed stated residents are getting their medications. All staff interviewed stated they have no knowledge of any medication errors occurring during their time at the facility. LPA Monter interviewed Health Services Director (HSD). HSD stated based on his/her time working at the facility, the residents have been getting their medication. HSD stated the facility is now using a new pharmacy for medications. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 5 Out of 6. Staff did not provide adequate laundry services to residents in care On January 27, 2025, the Department received a complaint alleging staff did not provide adequate laundry services to residents in care. On January 31, 2025, LPA Simi Rai interviewed Executive Director (ED) Kenia Padilla. ED stated some staff were not able to come to the facility due to being sick themselves, so ED stated she had hired agency to help with laundry services in the facility. ED stated they had agency staff in the community to help with laundry services. Based on records reviewed, the facility did hire agency services for the facility, for the month of January 2025. LPA Rai made the following observations during the complaint investigation: LPA Rai observed the laundry room. LPA Rai observed 3 washers, and 2 dryers. One dryer was out of service, but it is going to be repaired. On July 8, 2025, LPA Manuel Monter interviewed residents R1-R7. Residents R1-R6 stated they have not had any issues regarding their laundry. Residents R1-R6 stated they have not had any delays with their laundry service. Resident R7 was unable to respond to questions LPA posed. LPA Monter interviewed staff S1-S4. All staff interviewed stated the facility's laundry and dryer machines are functional. Staff S3 & S4 stated there has been a time when one of the washer machines was not working, but both staff interviewed stated maintenance fixed the washer machine. LPA Monter interviewed Health Services Director (HSD). HSD stated the facility washing machines and dryers are functional. HSD stated if they were to have any issues, they can call maintenance to fix it. During the tour of the facility, LPA observed the facility washer machines and dryers as functional. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 6 Out of 6.the state’s words, verbatim · CDSS document, Jul 8, 2025 · control 26-AS-20250127135342

Allegation investigated: Staff do not provide adequate supervision to residents in care. Staff are under the influence of alcohol and drugs while caring for residents. Staff are mismanaging residents' medications. Administrator is not present on facility premises for sufficient number of hours.

On 6/26/2025 Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit at the facility. LPA met with Regional Operations Specialist (ROS), Jessica Pryor and explained the purpose of the visit. Regarding the allegation of Staff do not provide adequate supervision to residents in care, Reporting Party (RP) stated that there has been many incidents of falls and residents passing away and NOC (night) shift employees disappearances. LPA Donato interviewed seven responsible parties. F1 mentioned that it is a nice, new facility and all the staff members are very kind and pleasant. There are many daily activities that R1 participates in and really enjoys the constant music and conversations. Overall, F1 is happy with the staff and how friendly and caring they are. page 1 of 3 Unsubstantiated The chef is amazing and always makes sure R1 likes what he/she is eating. F2 believes that R2 is being well taken care of. F3 shared that a private caregiver found R3 on the floor shaking and the facility called the paramedics and sent R3 to the ER. No video footage was available to review what happened or if R3 hit his/her head. F3 also mentioned that R4 is doing well, S5 has been great and seems to be well liked by family members of the other residents. They also love the head chef and activities director. F7 shared that the last few times they visited, they only had one caregiver on the floor who couldn’t leave, and the resident (R7) had to go to the bathroom. LPA also interviewed five staff members. S1 mentioned that he/she is not overwhelmed with work, its just enough. S3 and S4 shared that staff help each other out. However, S2 mentioned that An extra person will help a lot and they won’t feel so rushed if there is 4 people, S5 shared that there is not enough help during their shift. According to the ROS, there have since been an additional 6 staff members who were added to the roster, 3 of which are care staff and the other 3 are Licensed Nurses. When staff calls out, the facility calls for agency for coverage. LPA attempted to interview five residents but due to neuro cognitive disorder, they are not able to give answers. Regarding the allegation of Staff are under the influence of alcohol and drugs while caring for residents, RP stated that The Med Technicians are using substances narcotics and drinking alcoholic beverages and going to work like that. During the interviews, four staff members (S1, S2, S3, S4) shared that they haven’t seen any staff come in who are under the influence of drugs or alcohol. S5 did not answer the question. page 2 of 3 Regarding the allegations that Staff are mismanaging residents' medications. RP stated that Medication is not being given in a timely manner and is not being justified on the proper dosage being given as negligence. Based on records review, LPA reviewed 5 resident records. All medications are accounted for and given on the scheduled time. Regarding the allegation of Administrator (ADM) is not present on facility premises for sufficient number of hours, RP stated that the administrator does not run this facility correctly and in fact is never present at the facility to oversee anything that goes on there. During the staff interviews, S1 & S4 mentioned that every time that they are on shift the ADM is in the facility. S2 also shared that ADM is in the facility when he/she is working. S3 said that ADM is here every day. Based on interviews and records review, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Jun 26, 2025 · control 26-AS-20250515114342

Type of visit: Required - 1 Year

On 6/26/2025, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Regional Operations Specialist (ROS), Jessica Pryor and explained the purpose of the visit. LPA toured the facility and a random sample of resident rooms, common areas, and kitchen area. LPA observed some residents were having breakfast. All residents are currently housed on the 2nd floor. While touring the facility it was observed that the temperature was at 73 deg F. Hot water was also tested in the resident rooms and the temperature was at 110 deg F. All personal belongings of residents are intact. Facility has sprinkler system. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floors. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are done every quarter. Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. LPA requested following documents: Certificate of Liability Insurance & LIC500, LIC308, LIC610. No deficiencies are cited at this time. Report is reviewed and a copy is provided.the state’s words, verbatim · CDSS document, Jun 26, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management - other visit. LPA met with Regional Operations Specialist (ROS), Jessica Pryor. The purpose of the visit was to follow-up on a deficiency that was cited on 05/21/2025 regarding the observation of chemicals and hygiene products in 9 out of 11 dementia resident bedrooms, and to ensure the facility is adhering to their plan of correction submitted to the department on 05/22/2025. During today's visit, LPA toured the facility with the ROS to include 12 resident bedrooms. 7 out of 12 resident bedrooms observed with hygiene products, in which the 7 residents are diagnosed with dementia. Based on record review, the 7 residents are not at risk if allowed direct access to personal grooming and hygiene products. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Regional Operations Specialist, Jessica Pryor and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 18, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management - deficiencies visit due to violations observed during tour of the facility while conducting a complaint investigation for complaint control number: 26-AS-20240923130821. LPA met with Executive Director, Kenia Padilla Sanchez. During today visit, LPA toured the 2nd floor of the facility with the Executive Director (ED). LPA randomly entered into 11 resident apartments with the ED to include RM 232, 234, 236, 238, 237, 233, 229, 202, 201, 207, and 213. LPA observed 9 out of 11 resident rooms had hygiene products accessible to residents in care, located in the resident bedrooms and bathrooms. Items observed included shampoo, conditioner, lotions, perfumes, soaps, nail polish, and Clorox wipes. The rooms observed with accessible hygiene products/chemicals were rooms 232, 234, 238, 237, 233, 229, 202, 201, and 213. Based on interview with the ED, all residents on the 2nd floor are diagnosed with dementia and all the hygiene products and chemicals inside the resident bedrooms/bathrooms should be kept locked. A deficiency was cited per California Code of Regulation, Title 22. See LIC809-D. This report was reviewed with Executive Director, Kenia Padilla Sanchez and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 21, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: May 22, 2025

(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 is not met as evidenced by: Based on interview, record review and observation the licensee did not comply with the section cited above wherein chemicals and hygiene products were observed in 9 out of 11 dementia resident rooms which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 21, 2025

Plan of correction: Licensee states a plan to lock all chemicals/disinfectants. Licensee will submit a written plan and in-service staff training regarding the regulation cited to LPA Kabariti via email by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management - deficiencies visit due to violations observed during tour of the facility while conducting a complaint investigation for complaint control number: 26-AS-20240923130821. LPA met with Executive Director, Kenia Padilla Sanchez. During today visit, LPA toured the 2nd floor of the facility with the Executive Director (ED). LPA randomly entered into 11 resident apartments with the ED to include RM 232, 234, 236, 238, 237, 233, 229, 202, 201, 207, and 213. LPA observed 9 out of 11 resident rooms had hygiene products accessible to residents in care, located in the resident bedrooms and bathrooms. Items observed included shampoo, conditioner, lotions, perfumes, soaps, nail polish, and Clorox wipes. The rooms observed with accessible hygiene products/chemicals were rooms 232, 234, 238, 237, 233, 229, 202, 201, and 213. Based on interview with the ED, all residents on the 2nd floor are diagnosed with dementia and all the hygiene products and chemicals inside the resident bedrooms/bathrooms should be kept locked. A deficiency was cited per California Code of Regulation, Title 22. See LIC809-D. This report was reviewed with Executive Director, Kenia Padilla Sanchez and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 21, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: May 22, 2025

(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 is not met as evidenced by: Based on interview, record review and observation the licensee did not comply with the section cited above wherein chemicals and hygiene products were observed in 9 out of 11 dementia resident rooms which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 21, 2025

Plan of correction: Licensee states a plan to lock all chemicals/disinfectants. Licensee will submit a written plan and in-service staff training regarding the regulation cited to LPA Kabariti via email by POC due date.

Allegation investigated: Resident was covered in feces on hands and clothes due to staff neglect. Resident sustained a laceration on body but staff is unable to provide details of the injury.

Unannounced complaint visit made out to this facility on 12/15/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the weekend manager on duty, Jennifer DeLeon, who also held the role as the Memory Care Coordinator (Reflections Coordinator) at this time. A brief interview was conducted with the facility representative Jennifer DeLeon at this time. Current census was 30 residents. The purpose of this visit was to inform this facility, and its representative Jennifer DeLeon, that an ongoing investigation has been completed and the following findings were being delivered at this time. Based on interviews conducted during the course of this investigation, it was learned that this facility was licensed to accept and retain a total of 82 residents. It was learned that this facility accepted and retained residents diagnosed with varying levels of cognitive issues. It was learned that facility residents occupied both the first and second floors at this time. It was observed that there was an elevator that was used to access the second floor from the lobby. It was learned that there was one central entry/exit point leading out from the lobby area. Unsubstantiated Based on interviews conducted, it was learned that R1 was involved in an incident around July of 2023. It was learned that R1 was having an episode of aggression and behaviors related to R1's cognitive issues. It was learned that R1 did not want to cooperate with staff who were trying to change R1 since R1 was incontinent of bowel and bladder requiring R1 to wear depends. It was learned that R1 became even more agitated and started to use R1's hands, arms, and head to hit the floor. It was learned that it was from these actions performed by R1 which led to the abrasions and lacerations on R1's arms and hands. It was learned that facility staff called for assistance when it was discovered that R1 was starting to escalate in R1's agitative state and other facility staff members were available to respond and render assistance. It was learned that R1 was subsequently seen by a responding ambulance before being sent out to the local hospital for further evaluation. Based on interviews, it was learned that aside from this incident involving R1 being aggressive and non compliant with changing R1's depends, it was learned that facility staff were available to assist if residents needed any assistance. It was learned that there weren't any other incidents related to the one involving R1 and staff having to intervene. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred. There were no deficiencies observed or cited at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Dec 15, 2024 · control 26-AS-20231024163756

Allegation investigated: Neglect/Lack of supervision by staff to a resident who assaulted another resident.

Unannounced complaint visit made out to this facility on 12/15/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the weekend manager on duty, Jennifer DeLeon, who also held the role as the Memory Care Coordinator (Reflections Coordinator) at this time. A brief interview was conducted with the facility representative Jennifer DeLeon at this time. Current census was 30 residents. The purpose of this visit was to inform this facility, and its representative Jennifer DeLeon, that an ongoing investigation has been completed and the following findings were being delivered at this time. Based on interviews conducted during the course of this investigation, it was learned that this facility was licensed to accept and retain a total of 82 residents. It was learned that this facility accepted and retained residents diagnosed with varying levels of cognitive issues. It was learned that facility residents occupied both the first and second floors at this time. It was observed that there was an elevator that was used to access the second floor from the lobby. It was learned that there was one central entry/exit point leading out from the lobby area. Substantiated Based on interviews conducted during the course of this investigation, it was learned that R1 was very aggressive and often prone to physical confrontations with facility staff, residents, or other third party members who were present at that time. It was learned that facility residents were constantly in fear of R1 and had to tiptoe around R1 so as not to trigger any aggressive responses from R1. It was learned that facility staff were also working their shifts in fear of R1 and were always on high alert since they were well aware of R1's explosive behaviors and outbursts. It was learned that R1's behaviors were easily triggered and facility staff and visiting family members were unaware of what these triggers were so they had to always proceed with caution around R1 so as to avoid any physical confrontations. It was learned that R1 was in need of a one to one care situation since R1's behaviors and cognitive issues needed to be addressed with more direct supervision and redirection. It was learned that this issue of more direct supervision was not addressed until later on after several incidents had already taken place. It was learned that R1 was involved in several incidents involving other facility residents, staff members, and other third party members. It was learned that on one incident R1 was verbally abusive and grabbed hold of another resident and attempted to throw them to the ground. Another incident involved R1 taking a swing at a facility staff person causing harm and inflicting collateral damage to another resident who was just nearby. It was learned that R1 had gotten agitated and heated when attempts were made to redirect R1 to where it was learned that R1 picked up a cup of coffee and threw it into the face of a third party member. In addition, the splash from the coffee being thrown also ended up on another resident who was merely nearby. Incidents such as grabbing a residents eyeglass wear and throwing it for no apparent reason was also learned during this investigation involving R1. It was learned that later on, after all of these incidents and reported events to this facility were made, R1 did finally receive a direct one on one caregiver and was eventually moved out of the second floor down to the first floor. It was learned that R1 was kept on the first floor for a majority of the day along with R1's one on one caregiver and was brought back up to the second floor where R1 was then allowed to enter R1's bedroom to sleep at night. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated representative at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Dec 15, 2024 · control 26-AS-20231116110403

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 16, 2024

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 facility was found to be deficient as evidenced by a review of the facility forms and documents revealing that a resident required more one on one care and supervision, with redirection, which posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.the state’s words, verbatim · CDSS document, Dec 15, 2024

Plan of correction: The facility designated representative stated that the personnel requirements and scheduling will be updated to show that the proper level of staffing is being maintained at all times. A statement of correction, along with a copy of the most current staffing schedule for 24 hours/7 days a week coverage, will be completed and submitted into CCL by the due date.

Allegation investigated: Staff left medication unattended and accessible to residents in care.

Licensing Program Analysts (LPAs) Christine Dolores and Santino Fortes arrived unannounced to open the initial complaint investigation. LPAs met with Executive Director, Kenia Sanchez. On 10/07/2024, the Department received the complaint. On 10/17/2024, the initial complaint investigation was conducted. Documents were obtained to include the staff schedule for September 2024, resident roster, and a staff member’s telephone number. It was alleged that when staff (S1) assisted another resident, S1 had left "a stack" of bubble pack medications unattended and accessible to residents in care in the common area of the facility. Page 1 of 2. Unfounded On 10/17/2024, 3 staff members were interviewed. Based on interview, S1 stated to be discarding the monthly cycle of medications on the desk in the common area. S1 stated the bubble packs of medications that were sitting on top of the desk were being discarded and were empty bubble packs of medications. S1 stated there were no medications in the bubble packs. S1 stated that a resident had a fall in the common area just a few feet away from S1 and S1 turned his/her back from the desk with the empty bubble pack of medications. S1 denied leaving the common area and stated to have called a care staff to assist the resident. S2 corroborated S1’s statement. S3 denied the observation of medications being left unattended and accessible to residents. On 10/17/2024, LPA Dolores and LPA Fortes toured the facility to include the first and second floor. Based on observation, LPAs did not observe medications that were left accessible to residents in care. LPAs observed the medication cart located on the second floor was locked. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded meaning the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Kenia Sanchez and a copy of the report was provided. Page 2 of 2.the state’s words, verbatim · CDSS document, Oct 17, 2024 · control 26-AS-20241007160553

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Christine Dolores and Santino Fortes arrived to the facility unannounced to open the initial complaint investigation for complaint control number 26-AS-20241007160553. During tour of the facility, a violation was observed, therefore prompting a case management – other visit. LPAs met with Executive Director, Kenia Sanchez. During the tour of the facility, LPAs observed 2 out of 2 side exit gates located in the patio were locked using a combination lock. 2 out of 2 side gates are considered an emergency exit area. ED states the locks were implemented when ED started at the facility about 3 months ago. ED was unable to produce documentation to show a fire clearance approval to lock the exterior fence gates. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Executive Director, Kenia Sanchez and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 17, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(l)(2) · Plan of correction due date: Oct 18, 2024

(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not comply with the section cited wherein 2 out of 2 side gates in the patio were observed locked using a combination lock which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 17, 2024

Plan of correction: Licensee will remove the combination locks on the 2 side gates in the patio area and will replace the locks for a door alarm. Licensee will submit a picture of the 2 side gates and email communication regarding resolving the locks to the side gates to LPA Dolores via email by POC due date of 10/18/2024.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Kenia Sanchez. ADM stated the facility has 25 residents. LPA toured the facility inside out with ADM which included first floor and second floor of the residential area of the facility. LPA toured the Activity area, where residents were participating in a group exercise, then a word guessing game. The front yard and backyard were inspected. There was no obstruction to block the walkways. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 73 degrees F, and hot water temperature was measured at 114 degrees F in resident bathrooms. Fire extinguishers were serviced in June 2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Fire alarm system was last tested on March 2024. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on May 31, 2024. LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff and 2 residents. No deficiencies cited during today's visit. This report was reviewed with Administrator Kenia Sanchez and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Jun 21, 2024