Kingston Bay Senior Living

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

Allegation investigated: Staff inappropriately interacted in the presence of resident Staff do not safeguard resident's personal belongings Staff do not ensure resident's care needs are met Staff do not report incidents as required

Licensing Program Analyst (LPA) Katie Brown conducted a subsequent complaint investigation visit. LPA met with and explained the reason for the visit with Executive Director (ED) Arturo Correa. During this visit, LPA interviewed staff and residents as well as obtained records from staff files. This Department investigated the allegations listed above: Interview revealed that Staff S1 and S2 were witnessed in Resident (R1's) bedroom engaging in inappropriate physical interaction. S1 and S2 denied the allegations. However, their statements were inconsistent and changed over the course of the investigation. Additional staff members state they were unaware of a relationship between S1 and S2. Interview reports from Resident (R6), Staff and witnesses are inconsistant in whether R6 lost money, a lettery ticket or multiple lottery tickets. After losing the lottery tickets, R6 reports that a lock was placed on a drawer in the apartment to keep personal belongings such as a purse. R6's Physician Report dated 6/2024 states no Dementia or confusion. Additionally, facility Care Plans document R6 as independent. Unsubstantiated Continuation - page 2 Based on record review of Physician Reports and facility Care Plans, the residents identified do not all require the level of assistance identified. Residents interviewed gave conflicting statements to their care plans. Staff interviewed were consistent in explaining the process of communication within the team through the phone system when assistance is needed to provide 2 person transfers for residents. Interviews of Administrator (AD) and Director of Nursing (DON) were conducted and reveal the facility procedure for meeting reporting requirements. This Department interviewed a witness who confirmed communication from the facility related to an identified incident in the past. This was a requirement of the facility. Interviews with care staff reveal conflicting information regarding which department reports to whom when an incident occurs. A staff member reported that concerning matters can be reported to a Med Tech rather than to a Manager. The facility was unable to locate or provide a report of an incident regarding R6 which was said to have been submitted by previous Management. Based on interviews and record reviews the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 25, 2026 · control 24-AS-20250825091006

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Anna Porter and Brianna Miranda arrived unannounced to conduct the Annual Inspection. LPAs were met by and explained the reason for the visit with Administrator (AD) Mark Chisum. During this visit, LPAs toured the facility inside & out. Resident apartments contained required furnishings and lighting. The bathrooms were found to be clean and in good repair with faucets delivering hot water within required temperature. LPAs observed required hygiene items, towels, extra bedding, and linens which were stored and available for use. The kitchen was clean, with necessary items and appliances. LPAs observed required food supply and paper product storage. Cleaning/disinfecting supplies, knives and sharps are inaccessible to residents and stored separate from food. Medications are locked and centrally stored in medication carts. Medication rooms were locked when not in use. Common and activity areas were clean and occupied by residents throughout. Snack and water stations were available and observed to be well maintained. There are visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility. The Fire extinguishers were inspected on 3/16/2026 by Midstate Fire Co. Fire system maintenance was performed during inspection on 7/20/26. LPAs conducted staff and resident file reviews. A sample of resident medications was reviewed. R1's Haloperidol 1 mg, 30 count medication has 7 pills unaccounted for (30-21= 9). The facility has documented the PRN as being given twice, once on May 23, 2026 & again on July 14, 2026. Staff stated resident came from home with medication and medication should be counted and logged. LPA asked if R1's medication was counted and logged when they came to the facility and staff stated it was not. Centerally stored medication log was not completed for R1. PRN not completed for R1. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D in the areas of: An exit interview was conducted and Plan of Correction (POC) developed. A copy of this report was signed by AD and Appeal Rights were provided. LPA requested the following updated forms faxed to CCLD by 7/31/2026: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Emergency Disaster Plan (LIC610E), Client Roster (LIC 9020), Proof of current Liability Coverage.the state’s words, verbatim · CDSS document, Jul 20, 2026

Allegation investigated: Staff did not provide adequate transportation services

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint investigation. LPA met with and explained the reason for the visit with Administrator (AD) Alexis Alvarez and Jami Young (DON). During this visit, LPA obtained documents for review and conducted interviews. Interviews reveal that on 6/27/25, a resident suffered a heat-related incident in the facility van. While the facility rescheduled some afternoon activities due to summer heat, afternoon medical transportation continued. On 3/12/26, an inspection by the LPA, AD, and DON confirmed the van’s air conditioning was not operating at full capacity. Maintenance records for the van were provided and reviewed, but there is no documentation of air conditioning service. The preponderance of evidence standard has been met, therefore the above allegation found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were provided via email. Substantiated The Reporting Party did not identify a specific resident, date or incident to be investigated. Based on interview and record review the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 14, 2026 · control 24-AS-20250918130833

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87312 · Plan of correction due date: Apr 30, 2026

87312 Motor Vehicles Used in Transporting Residents Only drivers licensed... Any vehicle used by the facility to transport residents shall be maintained in a safe operating condition. This requirement was not met as evidenced by: Licensee did not ensure the facility van used to transport residents on outings and to appointments is maintained in a safe operating condition.The van air conditioning has not been maintained. 6/27/25 R1 became ill related to heat on a facility outong on the van. This is a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 14, 2026

Plan of correction: AD has agreed to submit a written statement to CCL which contains a plan to meet the requirements of the regulation as well as meets facility activities and appointment commitments. The plan will be submitted to CCL by poc date.

Allegation investigated: Staff do not address resident falls

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the initial complaint investigation. LPA Met with and discussed the allegations with Administrator (AD) Alexis Alvarez and Director fo Nursing (DON) Jamie Young. During this visit, LPA conducted inverviews and record review of Staff (S1) employee file. LPA was provided copies of facility documents for review as requested. This Department investigated the allegation above. The Reporting Party (RP) did not provide the name(s) of residents who have fallen or incident date(s). Interview with DON did not reveal or confirm a resident(s). The facility has fall procedures in place and staff have received training. Based on interview and record review the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 12, 2026 · control 24-AS-20260304165716

Allegation investigated: Staff member did not treat resident with dignity Staff member threatened resident. Staff did not prevent resident from threatening other residents in care Staff do not administer medications to residents as prescribed

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the initial complaint investigation. LPA Met with and discussed the allegations with Administrator (AD) Alexis Alvarez and Director fo Nursing (DON) Jamie Young. During this visit, LPA observed residents gathered in common areas including the lobby around the television. LPA conducted employee and resident interviews and was provided facility documents for review as requested. Interviews with both employees and residents consistently reported that there was an employee (S1) associated with facility management who worked in the facility for a short time. Interviews consistently report that S1 asked Resident (R1) to leave the lobby common area and go to their apartment to take a nap after falling asleep on a chair. Per interviews, the resident did not want to leave the area and was not forced to. Interviews reveal that R2 became very upset when a restriction was placed on the lobby television content. See continuation of this report LIC9099C Unsubstantiated Page 2 There are other televisions available in common areas of the facility other than in the lobby. Other than the Reporting Party, there were no other reports of anyone hearing or knowing about S1 threatening residents in any way. Staff schedules were reviewed and residents interviewed reported receiving medications on time. Based on observation, interview and record review the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 12, 2026 · control 24-AS-20260303095000

Allegation investigated: Staff exposed themselves to a resident

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint visit. LPA met with and explained the reason for the visit with Director of Nursing (DON) Jami Young, LVN. During this visit, LPA interviewed DON, obtained documents and delivered investigation findings. This Department investigated the allegation above. Interview and documentation provided by the facility confirm that Staff (S1) admitted that inappropriate interaction occurred in the presence of R1. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with DON, Jami Young, LVN. Substantiatedthe state’s words, verbatim · CDSS document, Dec 12, 2025 · control 24-AS-20250724162450

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Dec 22, 2025

Personal Rights of Residents in All Facilities 87468.1 (a) Residents in all residential care facilities... (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by Licensee did not ensure R1 was accorded dignity in their personal relationships with staff. After R1 reported to DON, S1 admitted to an inappropriate interaction of body exposure to R1 during care. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 12, 2025

Plan of correction: Administrator (AD) has agreed to provide staff inservice on Resident Personal Rights and Mandated Reporting. Inservice will include: Staff are provided a copy of LIC613C-2 (3/25) which will be reviewed. Additionally, Mandated Reporter requirements will be reviewed. A sign in sheet with nsmes and signatures of all AL and MC staff as well as a copy of training materials will be provided to CCLD via email by poc date.

Allegation investigated: Staff did not maintain a comfortable temperature for residents in care Staff are not following the facility menu

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the initial complaint visit. LPA met with and explained the reason for the visit and reviewed the allegations with Administrator (AD) Sarah Dennis and Director of Nursing (DON) Jami Young, LVN. During the visit, LPA conducted interviews, record reviews, observed lunch service and toured the kitchen. This Department investigated the allegations noted above. Interviews with AD and DON reveal that each resident has 1-2 Air conditioning units in their apartments. Residents reported their rooms being maintained at a comfortable temperature and if there is an issue, a work order can be made at the front desk. A record review was conducted of the work order log. There are work order entries "AC not working" that are "open" ranging from 1-7 days. In multiple apartments toured, the resident did not have the thermostat set correctly or even set to on. See LIC 9099C for Continuation of this report Unsubstantiated Page 2 This Department investigated the allegation: Staff are not following the facility menu. The facility has a set "restaurant style" menu listing meal options as well as offering daily specials for lunch and dinner. Residents consistently reported that there are times when they have run out of the daily special, specific side dishes or a preferred menu item. Residents also report that an alternative meal or item is always available. Based on interview, there are times when ordered items are not delivered and adjustments to the menu need to be made. Based on interview, observation and record review the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 11, 2025 · control 24-AS-20250902090350

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a Case Management - Health & Safety Inspection in conjunction with opening a complaint (control number 24-AS-20250825091006). LPA met with and explained the reason for the visit with Administrator (AD) Sarah Dennis. Upon arrival, LPA observed residents in the lobby and common area entry way. LPA and AD toured the facility with LPA randomly selecting resident apartments to observe on the first and second floor, including Memory Care (MC). Resident apartments toured were clean, have proper lighting and furnished as required. Bathrooms were clean, faucets delivered hot water, grab bars were in place and showers have slip resistant flooring. Residents have personal and extra supply of hygiene items, paper products, bedding and linens. There are multiple common areas for socialization. The activity calendar is posted and the activity room is available for use. Common bathrooms are clean and in good repair. LPA observed lunch being served in both Assisted living and Memory Care dining rooms. Medications are stored in locked Medication rooms. Cleaning/disinfecting supplies are locked and available to staff. LPA observed multiple housekeeping staff in resident rooms during the tour. Doors and passageways were unobstructed throughout the facility including outdoors. There were no citations during this inspection. An exit interview was conducted and a copy of this report was signed and providedthe state’s words, verbatim · CDSS document, Aug 26, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to complete the Annual Inspection. LPA met with and explained the reason for the visit with Administrator (AD) Sarah Dennis and Director of Nursing (DON) Jami Young, LVN. During this visit, LPA toured the kitchen which was found to be clean. Culinary staff was preparing for lunch to be served. Walk in refrigerator and freezers were observed at proper temperatures and contained required perishable food. Dry/Non-perishable food was observed and also properly properly stored along with Emergency food and water supply. Cleaning supplies are properly stored and First Aid kit was found to be complete. LPA and DON walked through Memory Care and observed resident apartments and the kitchen. LPA conducted a medication audit with DON as well as a continuation of resident file review. Employee file review was completed as well. Fire and Emergency Drills are in compliance. Infection Control and Emergency/Disaster Plans were reviewed. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D. A Civil Penalty is assessed for Repeat Violation on the attached LIC421M LPA requested the following updated forms faxed to CCLD by 9/1/2025 - Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Personnel Report (LIC 500), Client Roster (LIC 9020) and Proof of current Liability Coverage.the state’s words, verbatim · CDSS document, Aug 18, 2025

The state marks this report as 13 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a Case Management visit in conjunction with the Annual Inspection. LPA met with and explained the reason for the visit with Administrator (AD) Sarah Dennis. This Case Management is in reference to the SOC341 submitted by the facility on 7/28/2025. During this visit, LPA reviewed Resident (R1's) file, Staff (S1) and S2's files. LPA was provided copies of files as requested. LPA interviewed Administrator. There were no citations during this inspection. An exit interview was conducted, and a copy of this report was signed and providedthe state’s words, verbatim · CDSS document, Jul 29, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Administrator (AD) Sarah Dennis. LPA entered the facility into the lobby and observed common seating areas and a small bistro. LPA and AD began a tour where LPA randomly selected multiple resident apartments in Assisted Living (AL) and Memory Care (MC to be observed. The apartments and common areas were found to be clean, with furniture and flooring in good repair. LPA observed requirements met in restrooms throughout such as grab bars. slip resistant flooring and hot water at 105-107 degrees. LPA observed residents’ hygiene items, paper products, towels, bedding, and linens which were stored and available for use. Doors and passageways are unobstructed throughout the facility, including outdoors. Fire extinguishers were found to be charged and serviced 3/19/25 by Midstate Fire Co. LPA conducted resident file reviews. Due to time restraints, LPA will need to return to complete this inspection. There were no citations during this inspection. An exit interview was conducted, and a copy of this report was signed and providedthe state’s words, verbatim · CDSS document, Jul 29, 2025

Allegation investigated: Facility staff are not meeting resident toileting needs Facility staff do not respond to residents call buttons in timely manner Facility staff are not dispensing medication as prescribed

Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility to conduct a subsequent visit and derived complaint findings. LPA met with and explained the reason for the visit with Assistant Director of Nursing (ADON) Frankie Tamayo. Administrator (AD) Sarah Dennis arrived a short time later. During this visit, LPA conducted interviews, and reviewed Resident (R1's) medications. This Department investigated the following allegations: Facility staff are not meeting resident toileting needs: A record review was conducted of R1's file. Service Plan dated 3/27/25 which states R1 is independent with toileting, no assistance needed by staff. Physician Report dated 11/2024 - able to care for own toileting needs and transfers self. Per staff interview, staff assist R1 with the bedtime routine and may help with a nighttime brief. Unsubstantiated Page 2 - Continued This Department investigated the following allegations: Facility staff do not respond to residents call buttons in timely manner: Multiple residents were interviewed and report that the wait times after pushing the pendent button are too long. Residents also say that care staff enter the rooms, clear the pendent and leave again saying they will return soon. A report was obtained of R1's pendent report for 3/17/25. R1 pressed the pendent once at 6:03am and it was cleared within the hour. Facility staff are not dispensing medication as prescribed: A review was conducted of R1's medications as well as an audit of the facility documentation of the Medication Administration Record (MAR) of February 2025. Family takes R1 home for days at a time, when this happens medications are checked out from the facility, given at home and brought back after the visit. The facility MAR indicates when R1 is out of the facility. Additionally, interview reveals that the MAR does not record the actual time the Med Tech (MT) gives medications to R1, the system only records the time the records in the computer. Based on interviews and record reviews the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report was provided to AD.the state’s words, verbatim · CDSS document, Jul 18, 2025 · control 24-AS-20250320121934

Allegation investigated: Staff handled resident in a rough maner resulting in a skin tear

Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility unannounced to conduct an initial complaint investigation. LPA met with and explained the reason for the visit and the allegation with Administrator (AD) Sarah Dennis. During this visit, LPA also delivered investigatigation findings. On 5/25/25 around 4:00 AM, Staff S1 called for assistance because Resident R1 was being physically aggressive. S1 pulled R1 by the legs and then by the arms to move R1 away from R2 which caused R1 to sustain a skin tear on the right arm. Based on interviews conducted and staff statements reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD. Substantiatedthe state’s words, verbatim · CDSS document, May 28, 2025 · control 24-AS-20250527121130

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: May 29, 2025

87468.1 Personal Rights... (a) Residents .....shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This requirement was not met as evidenced by: Licensee did not ensure R1's personal rights were met. S1 pulled R1 by the legs and then by the arms to move R1 away from R2 which caused R1 to sustain a skin tear on the right arm. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Administrator has agreed to submit a written statement which will include a correction plan. The plan will include a staff inservice timeline and date that a sign in sheet with materials will be sumbitted to CCLD. The written statement will be submitted to by poc date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility unannounced to conduct a Case Management - Health & Safety Inspection in conjunction with a complaint visit (Complaint Control Number 24-AS-20250527121130). LPA met with and explained the reason for the visit with Administrator (AD) Sarah Dennis. During the visit, LPA met with Memory Care Director (MCD) Frankie Tamayo and Director of Nursing (DON) Jami Young, LVN in Memory Care. LPA observed residents sitting at tables and on couches in common areas. During a tour, LPA randomly selected multiple resident rooms to enter and observe. Resident rooms were clean and properly furnished. Resident bathroom sinks delivered hot water measuring between 106-109 degrees F. The laundry room was locked from the main hallway which is where extra bedding, towels and resident hygiene supplies are stored. Memory Care has a small kitchen accessible through a door which was locked to the main area. Food is delivered hot for each meal from the main kitchen and served to residents. The kitchen was clean and did not contain any sharps or knives. There is an office area which leads to the medication room which is locked. Medications are stored in a medication cart in the med room with resident files. First aid kits contain required items. Fire extinguishers were serviced by Midstate on 3/19/25. Doors and passageways are unobstructed throughout the facility including outdoors. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with DON.the state’s words, verbatim · CDSS document, May 28, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Jun 9, 2025

87309 Storage Space and Access (a)Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances,... in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidenced by: Licensee did not ensure items which could pose danger to R1 were locked and inaccessible. Per Physicians Report, R1 is at risk is allowed access to Hygiene items. R2's report is blank on #14j of the Physician report. Shampo, hairspray, cleansing spray and peri wash were left unlocked and accessible to residents.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Administrator has agreed to conduct a staff inservice to both AL and MC care staff to address item storage requirements. A complete sign in sheet will be submitted to ccld by poc date.

Allegation investigated: Staff does not ensure facility has adequate staffing to meet resident's needs Facility has pests Facility staff did not seek timely medical attention for resident Facility staff did not observe resident's change in condition

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint visit and deviver complaint findings. LPA met with and explained the reason for the visit and the elements of the allegations with Jami Young, DON. This Department investigated the allegation: Staff does not ensure facility has adequate staffing to meet resident's needs. Staff Schedule and time cards were reviewed for identified dates. Interviews reveal that there are shifts where there is 1 caregiver and on each floor of the Assisted Living portion of the facility. Between 2/15 - 2/16/25 Resident R1 experienced falls requiring hospitalization. It is unknown if the falls are related to lack of staff and supervision. See LIC9099C for continuation of this report Unsubstantiated Continuation - Page 2 This Department investigated the allegation: Facility has pests. The facility has a contract with Ecolab Pest Service. Receipts of service were provided and reviewed. There is a log maintained at the front desk where staff and family can report pests and request service. Facility maintenance or Ecolab sign off once the issue has been addressed. Sticky pads were observed in room 219 which are used as bait for roaches. Though small bugs were observed there is a procedure in place to address when identified. The Department investigated the allegations: Facility staff did not seek timely medical attention for resident and Facility staff did not observe resident's change in condition. Record review was conducted of R1's file and facility Observation Notes. The review confirmed that R1 had continued to become increasingly confused from 2/14-2/16/25. The notes show that facility staff communicated multiple times with R1's Responsible Party with updates on R1's increasing confusion including a fall on 2/15/25. Per the notes, Responsible Party repeatedly refused to send R1 to the hospital. It wasn't until R1 fell with injury and Paramedics spoke to Responsible Party that it was agreed that R1 would go to the hospital. The above allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report was left with DON.the state’s words, verbatim · CDSS document, May 23, 2025 · control 24-AS-20250221153510

Allegation investigated: Staff handles residents in a rough manner Staff speak inappropriately to residents in care Staff do not have required qualifications

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint visit and deliver complaint findings. LPA met with and explained the reason for the visit and the elements of the allegations with Jami Young, DON. This Department investigated the allegations Staff handles residents in a rough manner and Staff speak inappropriately to residents in care. Residents' R1, R2 and R4's statements were consistent during interviews that Staff S1 has been rough while providing care, S1 has spoken to residents in an intimidating, inappropriate manner. Residents report not wanting S1 to care for them. See LIC9099C for continuation of this report Substantiated Continuation - Page 2 This Department investigated the allegation: Staff do not have required qualifications. S3 was originally hired in Housekeeping. Interview and review of a staff schedule reveal that S3 began working as a caregiver in November 2024. Based on record review of S3's "User Learning", S3 did not complete the training requirements prior to working as a care provider. Additionally, S3's employee file was reviewed no record of First Aid Certification was located. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with DON.the state’s words, verbatim · CDSS document, May 23, 2025 · control 24-AS-20250225081339

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Jun 2, 2025

87468.1 Personal Rights...(a)...shall have the following personal rights (1)... .accorded dignity in their personal relationships with staff, residents, and other persons.This requirement was not met as evidenced by: Residents confirm S1 speaks in a demeaning manner and is rough causing discomfort during care. This is a potential health & safety risk to persons in care.the state’s words, verbatim · CDSS document, May 23, 2025

Plan of correction: Administrator has agreed to submit a written plan of action which will include a training plan. The written plan will be submitted to CCLD by poc date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Jun 2, 2025

87411 Personnel Requirements... (c) All RCFE staff... who assist residents with personal activities of daily living shall receive initial and annual training... This requirement was not met as evidenced by: S3 worked as a caregiver without completing RCFE requirements and without First Aid/CPR Certification. This is a potential health & safety risk to persons in care.the state’s words, verbatim · CDSS document, May 23, 2025

Plan of correction: Administrator has agreed to review the care staff training procedure with DON. A written statement will be submitted that the procedure has been reviewed and updated if needed. This statement will be signed by AD and DON and submitted to CCLD by poc date

Type of visit: Office

An Office meeting was held on 4/17/2025 at the Fresno Regional Office. The purpose of this meeting was to discuss identified issues/concerns associated with the operation of the facility. This office meeting process was explained to attendees. The following were in attendance: Michael Pittore Jonathan Karp Andrew Levin Terrijo Goldsmith Scott Hougham Sarah Dennis, Executive Director Sergiy Pidgirny, Licensing Program Manager Katie Brown, Licensing Program Analyst The following concerns were addressed: Complaint accumulation Staffing Concerns Reporting Requirements Licensee was provided with copies of applicable regulations and TSP was offered. A signed copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 17, 2025

Allegation investigated: Facility billed resident beyond the terms of the resident's Admission Agreement Facility did not assess resident at hospital for a change of condition prior to discharge

Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility to conduct a subsequent complaint visit. LPA met with and explained the reason for the visit and the elements of the allegations with Interum Administrator (AD) Rebecca Langdon. LPA delivered investigation findings to the facility during this visit. The Department investigated the allegation: Facility billed resident beyond the terms of the resident's Admission Agreement. R1 physically moved into the facility on 7/6/24. R1 was hospitalized 8/2-8/6/24. Resident was sent back to the hospital 8/6/24 after being determined by the facility that R1's needs could no longer be met. R1 did not return to the facility. R1's apartment was vacated on 8/13/24. Interview and record review confirm that R1 was charged beyond the specifications of the Admission Agreement which was signed 6/28/24. See LIC9099C for continuation of this report Substantiated The Department investigated the allegation: Facility did not assess resident at hospital for a change of condition prior to discharge. R1 was hospitalized 8/2 - 8/6/24. Interview and record review of R1's hospital record confirm that the facility did not conduct a reappraisal prior to discharge. R1 returned the the facility 8/6/24 after a telephone update had been provided by hospital staff. Per interviews and review of Incident Report, staff and the Director of Nursing (DON) observed R1's decline and changes of condition after R1's return. At this time, the facility determined that R1's current care needs could not be met. R1 was sent back to the hospital on 8/6/24. Based on interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 9099-D in the areas of Admission Agreements and Reappraisals. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were emailed to AD at Blangdon@agemark.comthe state’s words, verbatim · CDSS document, Dec 10, 2024 · control 24-AS-20241022083140

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Jan 7, 2025

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by: Licensee did not ensure compliance with all applicable terms of the Admission Agreement. R1 was not billed accurately according to the agreement after vacating the facility on 8/13/24. This is a potential health & safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 10, 2024

Plan of correction: Licensee has agreed to refund half month of July rent as written in Reservation Agreement and level of care as of 8/7/24, base rent as of 8/14/24 and level of care rent 6/30-7/5/24. Additional reimbursements noted upon review will also be provided to R1. A copy of the reimbursement statement will be submitted to CCLD by poc date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a)(3) · Plan of correction due date: Jan 7, 2025

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes ... The reappraisals shall document changes in the resident's physical, medical,(3) Any illness, injury, trauma, or change in the health care needs… This requirement was not met as evidenced by: R1 was accepted back to the facility with significant changes of condition. The facility did not conduct an assessment prior to discharge from the hospital. This poses a potential health & safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 10, 2024

Plan of correction: Licensee has agreed to review and revise procedures of resident assessment prior to return from a hospitalization. This procedure and will be emailed to CCL by the POC date.

Allegation investigated: Staff administered the incorrect medication to resident in care resulting in hospitalization. Staff did not report an incident involving a resident as required.

Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility to conduct the initial complaint visit. LPA met with and explained the reason for the visit and the elements of the allegations with Interum Administrator (AD), Rebecca Langdon. LPA delivered investigations to the facility during this visit. The facility reported the incident that staff administered the incorrect medication to resident in care resulting in hospitalization on 10/1/24 to CCLD as required. A Case Management visit was conducted on 10/23/24 resulting in a citation in accordance with California Code of Regulations, 87465(a)(4) Incidental Medical and Dental Care. The Department investigated the allegation: Staff did not report an incident involving a resident as required. The facility submitted Special Incident Reports (SIR) to CCLD as required which reported a medication error and that Resident (R1) experienced a fall resulting in medical attention and hospitalization. See LIC9099C for continuation of this reoprt Substantiated It has been confirmed that the facility notified the Responsible Party (RP) via phone to report the fall and that R1 was being taken to the hospital via ambulance. Interviews reveal that the facility discovered the medication error after R1 had been transported. The facility called and reported the newly reported medication error to RP who was already at the hospital. The facility reported to RP via phone but did not provide a written report of the incidents. Based on interview and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D in the area of Reporting Requirements. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and emailed to AD at Blangdon@agemark.comthe state’s words, verbatim · CDSS document, Dec 10, 2024 · control 24-AS-20241206171421

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jan 7, 2025

87211 Reporting Requirements (a) Each licensee shall furnish... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident... of the occurrence of any of (D) Any incident which threatens the welfare, safety or health of any resident… This requirement was not met as evidenced by: Licensee did not ensure that a written report was provided to the Responsible Person of R1 after a medication error and fall resulting in hospitalization. This poses a potential health & safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 10, 2024

Plan of correction: Licensee has agreed to review the current reporting procedure and update as needed. A copy of the updated procedure will be submitted to CCLD by poc date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Katie Brown arived unannounced to conduct a Case Management visit. LPA met with and explained the reason for the visit with Administrator (AD) Rob Huntley and Assistant Director of Nursing (ADON) Gaberiel Facio, LVN. The facility submitted Special Incident Reports (SIRs) which resulted in medication errors. On 9/29/24, Resident (R1) was given the wrong medication (another resident's medication). On 10/1/24, Resident (R2) was also given another resident's medication. R2 later experienced a fall and was evaluated at the hospital. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D in the area of Incidental Medical and Dental Care. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Oct 23, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 24, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care... by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Licensee did not ensure that the facility Med Tech assisted R1 and R2 with self-administered medications as ordered by their Physicians. R1 and R2 were given other resident's medications by facility Med Techs. R2 fell and required medical care.This poses an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 23, 2024

Plan of correction: AD has agreed to conduct a Med Tech in-service to review facility medication assistance procedures. AD will submit a written statement which includes the training plan and timeline of no more than 1 week. The inservice sign in will be submitted to CCL which includes names and signatures. Written statement to be submitted by poc date. Sign in sheet to be submitted after completion of training.

Allegation investigated: Staff does not provide residents clean linen Staff does not ensure cleaning and hygiene products are inaccessible to residents

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent visit and deliver complaint findings. LPA met with and explained the reason for the visit with Administrator (AD) Rob Huntley. During this visit, LPA conducted interviews. The Department investigated the allegation: Staff does not provide residents clean linen. On 8/12/24 Resident (R5’s) room was observed. R5’s bed sheets were found to be soiled with dried brown smears. Additionally, the same substance was observed on a shirt hanging in the closet and on the floor beside the bed. According to the housekeeping schedule, R5’s room had been cleaned (includes clean linens) on 8/10/24. See LIC9099C for continuation of this report Substantiated The Department investigated the allegation: Staff does not ensure cleaning and hygiene products are inaccessible to residents. On 8/12/24, resident hygiene products were observed in cabinets that were damaged or unlocked as well as body wash, shampoo, conditioner and mouth wash on the bathroom counters of residents in Memory Care with Dementia. On 9/7/24 conditioner was on the bathroom counter of R7 whose Physicians Report states cannot have access to hygiene and cleaning supplies. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD, whose signature on this form confirms receipt of these documents. note contradicting levels of staff assistance for eating. Other activities of daily living note extensive staff assistance required. The facility does not keep records of liquid intake, so it is unable to be determined R1’s fluid before and after hospitalization. Based on interview and record review the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report was left with AD, whose signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Sep 6, 2024 · control 24-AS-20240508111233

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(g)(1) · Plan of correction due date: Sep 16, 2024

87705 Care of Persons with Dementia (g)As required residents with dementia shall be allowed to keep personal grooming and hygiene items,. unless there is evidence… (1) Evidence means documentation from the resident’s physician... This requirement was not met as evidenced by: Licensee did not ensure hygiene supplies were inaccessable to residents. On 8/12/24 shampoo, conditioner, moulth wash were accessible in the bathrooms of R3 and R7. 9/5/25, conditioner was accessable in the bathroom of R7. R7's Physicians Report says R7 is at risk if accessible.the state’s words, verbatim · CDSS document, Sep 6, 2024

Plan of correction: AD agrees to conduct an inservice to MC staff on proper storage of hygiene items of residents with Dementia. Proof of in-service (sign in sheet) will be submitted to CCLD by poc date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 16, 2024

87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Licensee did not ensure that R5's bed linens were clean. Dry brown smears were observed on the sheets and floor. A damaged nightstand was observed ias well as damaged bathroom door frame in R7's room. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 6, 2024

Plan of correction: AD has agreed to in-service MC staff on housekeeping procedures and practice. Proof of inservice will be submitted to CCLD by poc date. The flooring in R5's room has been replaced, the nightstand was immediately removed from R7's room. Doorway has also been repaired.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to deliver Case Management – Health Checks findings. The initial Case Management visit was conducted on 8/12/24. LPA met with and explained the reason for the visit with Administrator (AD) Rob Huntley. A case management - Health Checks was conducted in conjunction with complaint control number 24-AS-20240404121910. Interviews and record review confirm that the facility was aware of the intimate relationship between Residents (R1) and R2. Precautions were not put in place to ensure the safety of R1. R1 has a diagnosis of Dementia. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D in the area of Basic Services and Reporting Requirements. An Immediate Civil penalty is assessed on the attached LIC421IM for Repeat Violation of absence of care and supervision. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Sep 6, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 9, 2024

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Licensee did not ensure R1's physical health, mental health, safety, or welfare once aware of the intimate sexual relationship between R1 and R2. The facility did not prevent multiple incidents of inappropriate interactions between R1 and R2. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 6, 2024

Plan of correction: AD agrees to submit a written statement to include training plan which will address the facility procedures and reporting if residents are found to be in an intamate relationship by poc date. Sign in sheet and copy of the facility procedure reviewed with staff will be submitted with in 14 days.

Allegation investigated: Staff did not prevent inappropriate interactions between residents in care Staff did not following reporting requirements

Licensing Program Analyst (LPA) Katie Brown arrived at the facility to deliver complaint findings. LPA met with and explained the reason for the visit with Administrator (AD) Rob Huntley. This Department investigated the allegation: Staff did not prevent inappropriate interactions between residents in care. Interviews and record reviews reveal the following incidents: On 3/13/23 staff found R1 unclothed in R2’s room. On 3/15/24, R1 was found by staff in R1’s bedroom, sitting on a char, covered in a bedsheet and R1’s feet were bound resulting in bruising. On 3/20/24, R2 was observed pulling R1 into a chair. On 3/21/24, R1 was found In R2’s bedroom, R2 was preventing R1 from exiting. On 3/27/24 R1’s feet had been tied together with clothing. On 3/28/24, R1 was found in R2’s bed topless and R1’s undergarment had been removed. R1 and R2 both have Dementia and reside in the Memory Care Unit. Once the facility was made aware of R2’s behavior, precautions were not put in place to ensure the safety of R1 and other residents. See LIC9090C for continuation of this report Substantiated Based on record review of Special Incident Reports (SIRs), facility staff observations and interviews, it is confirmed that R1 has aggressive and sexualized behaviors, but no safety plan was put in place. This Department investigated the allegation: Staff did not following reporting requirements. Record review of staff observations reveal that incidents occurred between R1 and R2 were not reported as required. The facility did not submit SIRs or reports of suspected abuse (SOC 341) as required for incidents which occurred on 3/13/24, 3/21/24 and 3/27/24. The incidents resulted unsafe, inappropriate interactions between R1 and R2. Additionally, facility did not report an incident which occurred 3/28/24 between R1 and R2 to law enforcement until the following day. Interviews reveal that that staff reported incidents and concerns to which were not reported to CCLD, Ombudsman or Law Enforcement as required. Based on record review and interviews, The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 9099-D in the areas of Basic Services and Reporting Requirements. An Immediate Civil penalty is assessed on the attached LIC421IM for absence of care and supervision. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 12, 2024 · control 24-AS-20240404121910

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 13, 2024

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Licensee did not ensure R1's physical health, mental health, safety, or welfare once aware of the behaviors of R2. The facility did not prevent multiple incidents of innapropriate interactions between R1 and R2. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 12, 2024

Plan of correction: AD has agreed to submit a written statement which outlines inservice for staff on care and supervision based on the regulations. Additionally, AD will include the steps to conduct a staffing review in MC. The statement will be submitted by 8/13/24. AD will include a date that the findings of a staff review will be submitted, no later than 30 days.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 26, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency... (1) A written report shall be submitted to the licensing agency... within seven days…(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by: Licensee did not ensure that Incident reports were submitted as required after incidents occurred which threatens the welfare, safety or health of R1.the state’s words, verbatim · CDSS document, Aug 12, 2024

Plan of correction: AD has agreed to provide in-service on reporting requirements to theNursing staff. Additionally, all care staff will be inserviced on Mandating Reporting Requirements. Proof of these trainings will be submitted on a sign in sheet with names and signatures by the poc date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a Case Management - Health Checks visit in conjunction with a complaint (Control Number 24-AS-20240404121910). LPA met with AD Rob Huntley and Assistant Director of Nursing (ADON) Jordan Valencia. During this visit, LPA toured the facility with AD, entering and observing resident apartments. LPA obtained copies from Resident (R1's) file. LPA also interviewed ADON. AD has agreed to provide LPA with August 2024 staff schedule for MC and AL. There were no citations issued. An exit interview was conducted and a copy of this report was left with AD, whose signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 12, 2024

Type of visit: Case Management - Other

On 7/12/2024 Licensing Program Analyst (LPA) Katie Brown arrived unannounced for a case management - other inspection regarding immediate exclusion of Staff 1 (S1). LPA met with Administrator (AD) Rob Huntley and stated the purpose of the visit. LPA discussed Staff (S1) with AD. LPA informed Administrator that S1 is excluded and cannot work or be on the premises of the facility and should be disassociated. During the visit, LPA confirmed that S1 was disassociated from the facility on 10/7/2022. No deficiency was observed. An exit interview was conducted and a copy of this report was provided to AD, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Jul 12, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Administrator (AD) Rob Huntley. During this visit, LPA toured the facility inside & out. Resident apartments contained required furnishings and lighting. The bathrooms were found to be clean and in good repair with faucets delivering hot water within required temperature. LPA observed required hygiene items, towels, extra bedding, and linens which were stored and available for use. The kitchen was clean, with necessary items and appliances. LPA observed required food supply and paper product storage. Cleaning/disinfecting supplies, knives and sharps are inaccessible to residents and stored separate from food. Medications are locked and centrally stored in medication carts. Medication rooms were locked when not in use. Common and activity areas were clean and occupied by residents throughout. Snack and water stations were available and observed to be well maintained. There are visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility. The Fire extinguishers were 3/28/24 by Midstate Fire Co. A fire inspection was conducted by Fresno fire on 4/11/24. LPA conducted staff and resident file reviews. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D in the areas of: Administrator - Qualifications and Duties, Oxygen Administration, Hospice Care and Resident Records. An exit interview was conducted and Plan of Correction (POC) developed. A copy of this report was signed by AD and Appeal Rights were provided. LPA requested the following updated forms faxed to CCLD by 7/11/2024: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Emergency Disaster Plan (LIC610E), Client Roster (LIC 9020), Proof of current Liability Coverage and Infection Control Plan.the state’s words, verbatim · CDSS document, Jun 11, 2024

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Katie Brown conducted a Health & Safety Inspection today in conjunction with opening a complaint (Control Number 24-AS-20240508111233). LPA met with and explained the reason for the visit with Administrator (AD) Rob Huntly and Director of Nursing (DON) Leonel Lopez. During this visit, LPA toured the facility, observing multiple randomly selected resident apartments. Apartments found to be properly furnished with required lighting. Each resident has a supply of extra towels and linens. LPA observed bathrooms to be clean with grab bars and non-skid shower floors. Hygiene supplies were properly stored and available. Medication rooms were observed during the facility tour. Residents were observed in Assisted Living as well as Memory Care having lunch, participating in activities or resting in rooms. Common areas are clean and available. Housekeeping carts were found to be locked in hallways while rooms are cleaned. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the home including outdoors. Fire Extinguisher service is up to date. During the facility tour with DON, LPA observed medications not stored appropriately in multiple apartments. A deficiency being cited in accordance with California Code of Regulations on the attached LIC809-D. A Civil Penalty is being assessed for a Repeat Violation on the attached LIC412FC An exit interview was conducted and a Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 9, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 10, 2024

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons.... This requirement was not met as evidenced by: Licensee did not ensure that resident medications were centrally stored and locked. LPA observed unsecured medications in the following apartmentts:125, 105, 110, 127, 137, 202, 242 and 231, 313.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: AD has agreed to bring in a designated staff member who will conduct a "sweep" of every apartment in the facility and remove any prescription or OTC medications, vitamins or supplements found. The medications will be properly stored. AD will provide a formal written statement by 5pm on poc date that states that the medication "sweep" of the entire facility is complete.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Katie Brown conducted a Case Management -Health Checks inspection in conjunction with a 10-day complaint visit. LPA met with and explained the reason for the Case Management with Administrator (AD) Rob Huntley. During a tour of resident apartments with AD and Director of Nursing (DON), LPA observed unsecured medications in the apartments of Residents (R1), R2 and R3. LPA conducted interviews and record reviews which reveal the residents noted above cannot store their own medications based of Phsician Reports and facility Care Plans. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC9099-D. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Apr 23, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Apr 24, 2024

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons.... This requirement was not met as evidenced by: Licensee did not ensure that resident medications were centrally stored and locked. LPA observed unsecured medications in the apartmentts of R1, R2 and R3.the state’s words, verbatim · CDSS document, Apr 23, 2024

Plan of correction: AD has agreed to submit a written statement which will include: resident apartments have been checked. AD will review and revise the assessment process for residents who store and are independent in medication management. Additionally included: staff in-service to review the requirements of medication storage and facility procedures (carestaff responsibility and reporting). A signed in-service sign in will be submitted with staff names and signatures. A copy of training materials will also be submitted to LPA by POC date.

Allegation investigated: . Questionable Death 2. Staff handle residents in a rough manner causing bruising 3. Staff do not distribute medication to residents as prescribed 4. Staff did not seek medical attention for resident in a timely manner

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent complaint visit and deliver complaint findings. LPA met with and explained the reason for the visit with Director of Nursing (DON) Leonel Lopez. During this visit, LPA interviewed DON, reviewed/obtained copies of resident files and interviewed residents. 1. The Department conducted a record review of Resident (R1's) facility file and obtained hospital medical records. R1 was admitted to the hospital 9/13/23. Staff charting notes 7/3/23-9/13/23 document R1's symptoms and changes as well as communication with family and physician. Medical records from the hospital do not mention suspision of abuse or neglect. 2. Based on interview, staff members do not report unknown bruising or injuries. Interviews reveal that if injury or bruising is noted, there is a reporting procedure. Residents were also interviewed and denied staff handeling them roughly. The resident noted by the Reporting Party passed away prior to the start of this investigation. Unsubstantiated 3. A record review was conducted of the Medication Administration Records (MARs) of the identified residents, including physician's orders. Residents were interviewed who state that they are assisted with/provided medications daily. Two of the residents identified passed away prior to the start of this investigation and another was independent in medication management at the time. Facility "Med Techs" were interviewed and medication procedure was reviewed. 4. A record review of facility documentation including "Observation Notes" (Med Tech charting) for R1 and R5 was conducted. Staff documented R1's symptoms and changes leading up to hospitalization on 9/13/23. R5's Observation notes as well as internal reports were reviewed and show that R5 sustained two falls, refused to be hospitalized and received X-Rays as ordered by Physician. Based on interview, record review and observation, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued An exit interview was conducted with DON and Administrator (AD) Rob Huntly. The report was signed by AD and emailed to rhuntly@kingstonbayliving.com.the state’s words, verbatim · CDSS document, Jan 8, 2024 · control 24-AS-20230919144634

Allegation investigated: Staff does not keep facility transportation bus clean Infection Control Procedures are not in place

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the initial 10 - Day complaint inspection. LPA met with and explained the elements of the allegations with Administrator (AD) Rob Huntley. During the visit, LPA toured the facility as well as the transportation van, conducted interviews and reviewed the facility Infection Control Plan and staff training logs. Based on observation and interview, the transportantion van was not clean. Trash were observed throughout, van interior needs to be cleaned and items properly stored to promote safety. Based on record review, staff have not completed required annual training in the area of Infection Control. The current Infection Control Plan needs to be updated. Five staff training files were reviewed during the visit. See Lic9099-C for continuation of this report Substantiated The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 9099-D in the areas of Maintenance and Operation and Infection Control Requirements An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed with and emailed to AD who signed the reports. Reports emailed to: rhuntley@kingstonbayliving.comthe state’s words, verbatim · CDSS document, Dec 20, 2023 · control 24-AS-20231214111001

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 29, 2023

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Licensee did not ensure the facility van was maintained in a clean, safe and sanitary condition. Trash was observed and personal items are not properly stored. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 20, 2023

Plan of correction: Administrator (AD) has agreed to develop a van maintenance procedure. Appropriate staff will be trained and a signed copy (AD, Maintenance Director and Driver) of the procedure will be emailed to CCLD by the POC date. AD has agreed to conduct inservice and training to meet annual infection control requirements. Once complete, staff will sign a log with the DON. The complete log will be emailed to CCLD by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(c)(1)(C) · Plan of correction due date: Dec 29, 2023

87470 Infection Control Requirements (c) An Infection Control Plan shall be developed…by the licensee and shall (1) The Infection Control Plan shall include all of the following: (C) An Infection Control Training Plan. This requirement was not met as evidenced by: Licensee did not ensure all staff are trained as required in the area of Infection Control. Five staff training logs were reviewed during the visit. This poses a potential health, safety or personal rights risk to persona in care.the state’s words, verbatim · CDSS document, Dec 20, 2023

Allegation investigated: Staff are not meeting residents incontinence needs

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a 10-Day initial complaint investigation. LPA met with and discussed the allegation with Administrator (AD) Rob Huntley and Director Of Nursing (DON) Leonel Lopez, LVN. During the visit, LPA conducted interviews and record review. Interviews reveal that Resident (R1) is independent of Activities of Daily Living (ADLs). Per AD and DON, the facility is aware of the change in R1's needs and increased odor which bother other residents in common areas. R1's care plan is in process of being updated though interventions are in process of being implemented. The above allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report was left with AD, whose signature confirms receipt of these documents. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 30, 2023 · control 24-AS-20231120094937

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.