La Marea Senior Living

Allegation investigated: Facility staff did not ensure residents responsible party was provided with detailed monthly invoices for care being provided Facility staff does not maintain financial records for residents in care

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to initiate and deliver findings for a complaint investigation regarding the above-mentioned allegations. LPA identified themselves and met with Executive Director Mariano Perez, to discuss the purpose of the visit and elements of the complaint. During the visit LPA collected facility records and interviewed staff. On 06/24/26 it was alleged "Facility staff did not ensure residents responsible party was provided with detailed monthly invoices for care being provided". The Department’s investigation consisted of unannounced facility visits, review of facility records, interviews with facility staff and LPA direct observations. Regarding the allegation, "Facility staff did not ensure residents responsible party was provided with detailed monthly invoices for care being provided", it was alleged that residents and responsible parties do not receive or have access to financial records. (Continued on LIC9099C, Page 2) Unsubstantiated Interviews with staff confirmed that monthly invoices are available to residents and responsible parties. S1 was able to demonstrate to the LPA that monthly invoices for family members had been linked to the old management system and were distributing invoices as expected. S1 told the LPA there is a website for families to check itemized charges for resident care. S1 stated the new management company has been diligent about addressing issues brought up to them since they took over at the end of 2025. S1 told the LPA that they have been updating the information and requesting family involvement to provide financial records. Records review of the facility's paperwork included notices to responsible parties and families about the changes and paperwork asking them to update the way they want to receive invoices. This corroborates staff interviews LPA Observed the computer program used to access monthly statements for families with itemized care charges. These observations confirmed staff interviews. On 06/24/26 it was alleged "Facility staff does not maintain financial records for residents in care" the Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff and LPA direct observations. Regarding the allegation, "Facility staff does not maintain financial records for residents in care", it was alleged that the facility has no financial records for residents and responsible parties. Interviews with staff confirmed that financial records for residents from the original management company up to the initial opening of the facility are kept and maintained. S1 stated to the LPA that the facility is currently updating and auditing the finances to reflect unpaid charges and credits to responsible parties of residents. Records review of the facility's financial records included itemized billing and past records dating back to 2021/ licensure of the facility. This corroborated staff interviews. LPA observed the computer program used by staff with financial records documenting resident accounts. These records dated back to the initial opening of the facility. These observations confirmed staff interviews. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Mariano Perez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jul 1, 2026 · control 08-AS-20260624134830

Allegation investigated: Untrained staff providing care and supervision.

On 06/25/2024 it was alleged that "Untrained staff providing care and supervision." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff and records review. Regarding the allegation, "Untrained staff providing care and supervision.," it was alleged that facility staff are not trained properly before providing care and supervision to residents. Records review of the facility staff training records indicated that training is not standardized for each staff member in the same roles. Additionally, the training subject matter listed under CCLD guidelines required for facility staff is not fulfilled by all members of the staff. The LPA reviewed care staff and found that nine (9) of the total forty (40) audited did not have the required training. (COntinued on LIC9099C, Page 2) Substantiated (Continued from LIC9099, Page 1) Based on records review, the preponderance of evidence has been met that alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with the executive director, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were providedthe state’s words, verbatim · CDSS document, May 21, 2026 · control 08-AS-20240625130417

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Jun 19, 2026

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 Based on observation and interview, the licensee did not comply with the section cited above in ensuring all staff were trained per CCLD requirement which poses a potential immediate health, safety or personal rights risk to 109 of 109 persons in care.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: Licensee will provide training to staff members and provide proof through signatures and updated training logs. This proof will be provided to CCLD offices by 06/19/2026.

Allegation investigated: Staff did not notify authorized representative of incident Residents are not treated with dignity and respect

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive DIrector Mariano Perez. On 08/27/2024 it was alleged that "Staff did not notify authorized representative of incident" The Department’s investigation consisted of unannounced facility visits, interviews with facility staff and residents, and records review. Regarding the allegation, "Staff did not notify authorized representative of incident," it was alleged that Resident 1 (R1) received a serious injury and the responsible party (RP)/Power of Attorney (POA) was not notified per licensing requirements. (Continued on LIC9099C, Page 2) Unsubstantiated (Continued from LIC9099, Page 1) Interviews with facility staff revealed that facility staff unanimously could not state to the LPA how the resident received the injury almost two years ago to the date of the initial complaint, who treated it at the time, and whether or not it was reported to the POA. All interviewed staff agreed that the preferences of reporting incident reports and other reportable events to the POA for R1 were to be communicated by phone when the POA was not at the facility visiting R1. Facility staff agreed that most reports were communicated verbally when the POA would visit on a daily basis. Records Review revealed that the staff were aware of the injury. Care notes from the facility dated on 07/11/2024 at 1:56 AM stated, "Resident has a skin tear on their left shin. Medtech cleaned the area and put on a large band aid." In an email sent directly to facility staff about R1's care from the POA, it was stated that they were never notified through phone that R1 received the injury on their lower left extremity nor was the POA emailed a response by facility staff. In several other emails sent to the LPA by the POA of their conversations with the facility, it was stated that the POA visited R1 on a daily basis almost without fail and received verbal updates from staff in addition to phone calls. The regulation of CCR Title 22 87211 Reporting requirements states that a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D); (B) Serious injury as determined by the attending physician and occurring while the resident is under facility supervision. Welfare and Institutions Code Section 15610.67 provides: “Serious bodily injury” means an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation. The skin tear injury that R1 sustained does not fall under this definition and is not considered a serious injury and was not required by licensing requirements to be reported to CCLD offices or to the representative. Based on interviews, direct LPA observations and records review, a preponderance of evidence does exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. (Continued on LIC9099C, Page 3) (Continued from LIC9099C, Page 2) On 08/27/2024 it was alleged that "Residents are not treated with dignity and respect" The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "Residents are not treated with dignity and respect," it was alleged that facility staff taunt and act malicious towards R1. Interviews with staff revealed that staff unanimously did not witness other facility staff members acting malicious towards R1 or treating R1 without dignity and respect. Staff unanimously described R1 as a "sweet resident" who was often in pain and would become agitated during care due to their pain and sensitivity threshold. Caregivers and medical technicians encouraged other staff to seek help and avoid situations of being alone when R1 became aggressive. Multiple interviews with facility staff indicated srhey were concerned with R1's family interfering with R1's care and personal rights by denying the resident their rights to refuse medication and to have a schedule that reflected their wants and desires. An example provided by the POA to the LPA of lack of dignity and respect included a picture of R1's toes exposed through a purposefully cut and manicured sock. Facility staff unanimously told the LPA that this was due to R1's documented complaint of sensitivity and pain especially in their toes and feet. In this instance, the facility was responding to R1's needs and did not perform this act with malicious intent. Interviews with residents revealed that residents have not witnessed malicious acts from staff towards residents or that residents are not treated with dignity and respect per CCLD guidelines. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Mariano Perez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were providedthe state’s words, verbatim · CDSS document, May 21, 2026 · control 08-AS-20240827162536

Allegation investigated: Questionable death Staff did not ensure medications were dispensed as prescribed

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive DIrector Mariano Perez. On 04/02/2026 it was alleged that the facility was responsible for a "Questionable Death." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, outside sources, and records review. Regarding the allegation, "Questionable Death," it was alleged that a resident's cause of death was an overdose of over the counter brand decongestant Mucinex. (Continued on LIC9099C, Page 2) Unsubstantiated (Continued from LIC9099, Page 1) Interviews with outside sources confirmed that there was an investigation performed by California Department of Pubic Heath (CDPH) into the reporting parties allegations. Outside Source 1 (OS1) stated that the hospice provider Resident 1 (R1) was receiving treatment with was investigated by the CDPH and allegations with identical claims were found to be unsubstantiated based on the evidence of the investigations. Additionally, OS1 stated there was another investigation performed by a nurse investigator who included a review of the facility and found the claims were unsubstantiated as well. Outside Source 2 (OS2) told the LPA that "without evidence of significant overdose or allergic reaction, it would be difficult to establish a causal link between Guaifenesin (Mucinex) dosage and death in a 99-year-old resident." Records Review revealed that the death certificate of R1 listed the cause of death as Organ Failure, with Cardiac Disease as a contributing factor. The circumstances noted do not indicate an unnatural or questionable death. This corroborates outside source interviews. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. On 04/02/2026 it was alleged that "Staff did not ensure medications were dispensed as prescribed" The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, outside sources, and records review. Regarding the allegation, "Staff did not ensure medications were dispensed as prescribed," it was alleged that facility staff did not follow the prescribed directions of administering decongestant Mucinex to R1. Interviews with facility staff revealed that R1 was not taking the medication outside of the recommended dosage or outside of the attending physician's orders. (Continued on LIC9099C, Page 3) Interviews with outside sources confirmed that there was an investigation performed by CDPH into the reporting parties allegations. OS1 stated that the hospice provider R1 was receiving treatment with was investigated by the CDPH and allegations with identical claims were found to be unsubstantiated based on the evidence of the investigation. Additionally, OS1 stated there was another investigation performed by a nurse investigator who included a review of the facility and found the claims were unsubstantiated as well. According to Outside Source 2 (OS2), "Guaifenesin (Mucinex) at recommended doses is not known to cause organ failure or cardiac death. The FDA-approved labeling for Mucinex (guaifenesin alone) does not list cardiac disease as a contraindication, nor does it warn about organ failure or cardiac complications when used at recommended doses." Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive DIrector Mariano Perez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 21, 2026 · control 08-AS-20260408113608

Allegation investigated: Resident in care eloped from facility and sustained multiple injuries

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director (ED) Janet Miller. On 09/28/21 it was alleged "Resident in care eloped from facility and sustained multiple injuries." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, Resident 1 (R1) eloped from the facility during the night and found their way to the hospital after they sustained injuries (bruises and scratches) after falling during the elopement. (Continued on LIC9099C, Page 2) Substantiated (Continued from LIC9099, Page 2) A records review of the incident showed that both a physician's report dated 08/30/21 and a resident appraisal (no date) diagnosed R1 with Parkinson's disease, insomnia, and gait instability. The physician's report stated that R1 was not able to leave facility unassisted. The Resident Appraisal listed the history of R1 having been hospitalized on three separate occasions: twice due to falling down stairs and once due to insomnia induced hallucinations. On the ISL Base Level of Care Assessment performed on 09/09/2021, it was determined that R1 was a fall risk and required escort services up to three times a day. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with ED Miller. An exit interview was conducted with ED Janet Miller, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 26, 2026 · control 08-AS-20210928124543

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Mar 27, 2026

87464 Basic Services "(f) Basic services... include: (4) Personal assistance and care as needed by the resident... indicated in the pre-admission appraisal... such as dressing and assistance with taking prescribed medications..." Based on observation and record review, the licensee did not comply with the section cited above in ensuring resident was supervised as needed which posed an immediate health, safety or personal rights risk to 1 of 120 persons in care.the state’s words, verbatim · CDSS document, Feb 26, 2026

Plan of correction: Executive DIrector will show CCLD offices proof of In-service training on appraisals, elopement procedures, and Parkinson's education by 03/27/2026.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Executive Director (ED) Janet Miller. The facility's license shows a maximum capacity of one hundred twenty-five (125) non-ambulatory residents, fifteen (15) of whom may be bedridden. Hospice waiver for fifteen (15) and the facility is approved for delayed egress on the first floor. During today’s inspection there were one hundred and seventeen(117) residents in care. During today’s visit, LPA with ED toured the interior and exterior of the facility, and inspected a sample of rooms. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per ED, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. No deficiencies were cited during the inspection. An exit interview was conducted with ED Miller to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 26, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced case management visit to conduct follow up regarding background check requirements for Staff 1 (S1). LPA was greeted by, identified themselves to, and explained the purpose of the visit with Executive director (ED) Johnathan Thomas . On 1/27/2026, the Department conducted an investigation and found additional violations. During today’s visit, LPA conducted a health and safety check, reviewed facility records, and interviewed staff. The following deficiencies were cited for Background check violations and noted on the attached LIC809-D page. Additionally, a civil penalty in the amount of $500 was assessed for no criminal record clearance for one staff member and noted on the attached LIC421BG form. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with ED Johnathan Thomas, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 10, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Feb 10, 2026

87355 Criminal Record Clearance(e): All individuals... shall prior to working.. in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department… Based on interview and record review, the licensee did not comply with the cited section that Staff 1 had been working at the facility for at least 5 calendar days and did not have a criminal background clearance association, which poses an immediate safety risk to 108 of 108 residents in care.the state’s words, verbatim · CDSS document, Feb 10, 2026

Plan of correction: The Executive Director will not allow Staff 1 to return to the facility until the staff is associated to the facility through Guardian/LIS systems. Exectuve Director will send proof to CCLD Offices of Association for Staff 1y 02/17/2026

Allegation investigated: Staff did not prevent an adult at the facility from touching a resident inappropriately

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Johnathan Thomas. On 12/16/2025, it was alleged " Staff did not prevent an adult at the facility from touching resident inappropriately." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, " Staff did not prevent an adult at the facility from touching resident inappropriately.", it was alleged that Resident 1 (R1) had been sexually assualted by a facility staff member during an event held at the facility. (Continued on LIC 9099C, Page 2) Unsubstantiated (continued from LIC9099, Page 1) Staff interviews revealed that Staff 1 (S1) and Staff 2 (S2) were alerted to the alleged incident on 12/12/25. S2 attested that a caregiver was assisting R1 when they told the caregiver they were sexually assaulted by someone at the facility back in June 2025. S1 notified police of the incident, and an investigation was opened. S2 spoke with family of R1 to notify them that the facility took the accusation seriously and made accommodations to make R1 feel safe at the facility while the investigation took place. Staff 3 (S3), whom sees R1 on a regular basis, stated in an interview that they were not aware of anyone hurting R1 and that R1 rarely leaves their room. Resident interviews revealed that R1 was unable to consistently describe the incident that took place. R1 stated that they believed a facility staff member was responsible for the alleged abuse. Additionally, R1 stated to the investigator they enjoy staying in their room, which corroborated staff interviews. Records review revealed that in a physician’s report dated on 8/31/2025, R1 is currently diagnosed with Major Neurocognitive Disorder. Outside Source interviews revealed that Outside Source 1 (OS1) was with R1 the entire day during the June 2025 event at the facility. OS1 confirmed that no one could have abused R1 during that time and that no such incident occurred. OS1 continued to state to the investigator that R1’s diagnosis had contributed to the alleged event and stated they had no concerns with the facility or that R1 was at risk for being sexually abused by facility staff. Based on interviews, Investigator observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with ED Johnathan Thomas, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 9, 2026 · control 08-AS-20251215140338

Type of visit: Case Management - Other

Licensing Program Analyst(LPA) Janet Ngallo conducted an unannounced case management visit to provide the facility with an amended deficiency page from the visit conducted on 10/20/2025. LPA was welcomed by and discussed the purpose of the visit with Johnathan Thomas. No deficiencies were cited during today's visit. An exit interview was conducted with Johnathan Thomas to whom a copy of this report was provided. Their signature below confirms receipt of this document.the state’s words, verbatim · CDSS document, Nov 24, 2025

Allegation investigated: Staff are mismanaging residents medications.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Johnathan Thomas. On September 16th, 2025, it was alleged that the staff mismanaged resident’s medication. The Department’s investigation consisted of an unannounced facility visit, records review, staff, and outside source interviews. According to the allegation received, Resident #1 (R1) was not given their medication for 9 days. It was alleged that due to R1's lack of medication, R1 showed extreme emotional symptoms. It was alleged that staff notified R1's POA about the medication running out several days after R1 had not been taking said medication. [Continued on LIC9099-C] Substantiated Review of facility records revealed that facility staff had self reported this medication error for R1 to the department on September 18th, 2025. The records reviewed stated that on 09/08/2025, R1 ran out of their medication, and medication was not delivered until 09/15/2025. Interviews with staff and outside sources all corroborated that R1 had not been given medications for several days. R1 did have some emotional adverse reactions presumably due to the lack of medication. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of evidence exists to support the allegation. One deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Johnathan Thomas, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.the state’s words, verbatim · CDSS document, Oct 20, 2025 · control 08-AS-20250916112659

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 20, 2025

87465 Incidental Medical and Dental Care: "(a)(4) The licensee shall assist residents with self-administered medications as needed." This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the sections cited above as one(1) out of one hundred and twenty-five(125) residents did not recieve medication, which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 20, 2025

Plan of correction: Licensee will conduct an in-service training due on 10/23/2025 as a result of the medication error. Licensee will provide proof of training with sign-in sheet and training topic.

Allegation investigated: Staff are not checking on residents at night

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit for a complaint investigation. LPA identified herself and discussed the allegation mentioned above with Senior Business Office Director, Reika Villagomez Marron and Generation Program Director, Daisy Rodriguez. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff and outside sources. It was alleged staff are not checking residents at night. It was reported that Resident #1 (R1) was not checked on by the NOC shift staff on 10/04/25, from 9:15pm to 6:30am. It was also reported R1 was calling out for help and asking for water. The NOC shift hours are from 10:30pm to 6:30am. R1 resided in the secured memory care unit. R1’s Physician Report dated 08/01/25, indicated R1 had a diagnosis of a Major Neurocognitive Disorder. It also reflected that R1 was incontinent of bladder, required assistance with transferring/repositioning, bathing, dressing/grooming, and medication management. A review of R1’s records indicated R1 was receiving hospice services. Continued on LIC 9099C. Substantiated The Generation Program Director (GPD) explained residents in memory care don’t typically receive a call pendant due to their cognitive ability. However, R1 was provided with a call pendant due to having private companions. If assistance was needed prior to the staff making their rounds, then the private companion would push the pendant and alert staff. The private companions do not provide care, the facility staff are responsible for the residents’ care needs. The facility’s policy for their memory care unit is that staff check residents according to their care plan, as needed, and/or every 2-3 hours per shift. The GPD explained that most residents are asleep at night. However, some residents require incontinent care, which is provided by the NOC shift staff. The NOC shift will provide incontinent care at the beginning of their shift, the middle of their shift, and at the end of the shift. Staff will also provide additional care if needed. GPD stated residents have a care plan, which is followed by the staff, as each resident has different needs. The Outside Source stated staff did not check on R1 on the evening of 10/04/25. The memory care unit has 2 staff on the NOC shift: 1 Medication Technician (med tech); and 1 caregiver. In the memory care unit during NOC shift the med tech steps into the role of a caregiver and provide care to residents. The facility will also use caregivers from their Assisted Living portion of the facility when needed. Staff #1 (S1) was working the NOC shift on 10/04/25. It was determined that S1 was under the assumption that due to R1 having a private companion, there was no need for a routine check. The GPD explained to S1 that all residents are checked regardless. The GPD also explained S1 was under the impression that if R1 needed assistance, the private companion would use the call pendant. Based on evidence, S1 did not check in on R1 during the night of 10/04/25. A review of R1’s call pendant log for 10/04/25 indicated the pendant was activated at 5:03pm and 5:07pm, there were no other calls for assistance indicated. S1 has been made aware by management that all residents must be checked, regardless of private companions. Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Senior Business Office Director, Reika Villagomez Marron whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Oct 13, 2025 · control 08-AS-20251007103525

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Nov 10, 2025

Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers...In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care...The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents…require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on interviews and record review the licensee did not ensure residents were checked on during the night for 1 out of 89 [R1] residents, which posed a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 13, 2025

Plan of correction: The Generation Program Director explained training was provided to S1. However, all staff will be trained on routine checks. Proof of training is due by POC due date.

Allegation investigated: Facility staff failed to keep resident hydrated resulting in acute kidney injury.

On 9/29/2025, LPA Grace Donato conducted a telephone interview with the facility to deliver findings. LPA spoke with Executive Director Johnathan Thomas and explained the purpose of the call. Regarding the allegation Facility staff failed to keep resident hydrated resulting in acute kidney injury, Reporting party (RP) stated that RP was concerned because resident (R1) was severely dehydrated. During the investigation, staff members were interviewed, and records were reviewed. According to staff interviews, all mentioned that R1 liked to drink coffee and water and R1 would often ask staff for water throughout the day. R1 had a personal water glass that is kept beside R1s bed and staff would fill it whenever it got low. S1 mentioned that when R1 would wake, R1 always asked for coffee and water. page 1 of 2 Unsubstantiated S2 added that staff would periodically refill the glass (that was kept beside the bed) throughout the day and encourage R1 to drink water. S3 shared that staff would sit with R1 during meals to assist R1 to eat and drink. S4 added that when S4 worked the night shift, S4 would always see R1 in the dining room for dinner. R1 would eat the majority of the food and R1 would drink coffee and water with R1s meal. S4 said R1 would ask for a snack and staff would give R1 half of a sandwich or something else R1 would request. R1 often had a snack with a glass of water during the evening before staff brought R1 back to the room for bed. The nurse practitioner (N1) of R1 was also interviewed and it was shared that staff would encourage R1 to eat and drink fluids and assist R1 when needed. N1 said R1 was having difficulty feeding himself/herself and drinking due to R1s weakening condition. Staff would sit with R1 during meals to assist R1 and ensure R1 ate and drank fluids. N1 said the last time N1 visited R1 before R1 went to the hospital. Although R1 was sleepy and appeared weak, all R1s vital signs were normal, and did not see any signs of dehydration. Based on interviews, observations and records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Sep 29, 2025 · control 08-AS-20240220115737

Allegation investigated: Facility neglect resulted in resident sustaining fractures while in care Staff did not provide timely medical assistance to resident after a fall Staff did not notify resident’s family member of changes in residents condition Facility did not report incident

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced visit to deliver investigative findings regarding the above-mentioned allegations. LPA identified herself and was granted entry by Executive Director Johnathan Thomas. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director Thomas. The Department’s investigation consisted of interviews with staff and outside sources and record review of relevant documents pertinent to this investigation. On March 22, 2024, it was reported that Resident #1 (R1) sustained fractures due to neglect resulting in a fall while in care, and, that R1 was not provided timely medical assistance after the fall. It was also reported that staff did not observe R1 for their change in condition, and that the facility did not report incidents as required. [CONTINUED ON LIC9099-C] Substantiated The Department obtained R1's facility records, which indicated they moved into the facility in November of 2023. Their October 2023, Physician’s Report indicated that they were non-ambulatory and required assistance with transfers and bathing, which was to be provided twice per week. Prior to their move-in, they were diagnosed with a cracked vertebra and were considered a high fall risk. They required daily routine checks and escorts with staff, along with using a walker for long distances. According to two staff members (S2 and S3), there were times when R1 did not recall that they needed their assistive device, and would forget to use it when walking. According to a Service Plan dated December 29, 2023, R1 also had a risk of skin breakdown and required daily skin checks in which staff were to look for redness, discoloration, or open areas of the skin. Staff were to provide bathing, which included monitoring for skin issues twice a week. According to the Pre-hospital Patient Record, R1 was also on blood thinner medication. Facility case notes revealed that on November 11, 2023, R1 sustained a witnessed fall within their first week of care, which resulted in a skin tear. According to facility notes, R1 did not complain of pain, and minor first aid was provided. R1’s Responsible Party (RP) was notified on the same day, which was corroborated by RP when interviewed by the Department on April 12, 2024. 10 days after the fall, on November 21, 2023, the facility noted a change in condition, as R1 began to present with discoloration in their leg. No notation was made indicating that R1’s RP or Physician was informed on the day of the observation, nor was medical care obtained. It was noted that the RP was notified more than 24 hours later, which was corroborated during an interview with RP. On November 22, 2023, an Outside Source (OS1) expressed concern regarding the facilities delay as R1 was on blood thinners, which means “she’ll bleed more”. On December 2, 2023, staff annotated R1 had a hematoma on the left side of their hip, however it was also noted that RP was not made aware until one day later, December 3, 2023. In February 2023, R1’s case notes indicated that a staff member [S1] observed them with an unexplained skin tear to the right arm and a bruise on the wrist. It was noted that another staff member was notified, but not R1’s Responsible Party, which was corroborated by RP. [CONTINUED ON LIC9099-C] In March, R1 complained of pain to an Outside Source (OS1), and said that it was because they had fallen. On March 7, 2024, OS1 contacted facility staff (identity unknown), who replied that they conducted a check on R1 and found them in bed. Several days later, another outside source (OS2) visited R1 and observed them crying with pain. When questioned by OS2, staff reported R1’s crying was due to soreness from walking. The Department interviewed staff member #2 (S2), who was present at the time and stated they were aware that R1 had fallen. S2 clarified they reported it to another staff member (S1), and mobile medical care was ordered. According to Mobile Medical Records dated 3/6/23, R1 was seen for severe pain in the hip and groin areas, and 911 and transfer to the hospital were required and activated. However, interviews with OS1 and staff (S1, S2, S3), Ambulance Records, and Hospital Admission records all indicated that 911 was not activated until 4 days later, March 10, 2024, where R1 was diagnosed with a closed fracture of the sacrum and coccyx, and a compression fracture of their vertebra. A review of facility case notes further revealed there were no documented notes regarding R1 from February 20, 2024, to March 9, 2024, which included the dates concurrent with their fall. A further review of Department records revealed that eighteen days later (3/28/2024), the facility reported the incident to the department, eleven (11) days later than required. Over the course of R1’s residency, records indicated the presence of 5 unexplained injuries while in care. Multiple staff members, S1, S2, S3, and a former Executive Director, were aware R1 was a fall risk and needed assistance with escorting daily. The Department interviewed several staff members who were aware of R1’s falls (S1, S2, and S3), including former Memory Care Director and Executive Director, and all reported that no additional interventions were put in place to mitigate the risk of injury or fall. On April 12, 2024, the Department interviewed the Executive Director (ED), Gregory Case who had been responsible for the facility for approximately one month before R1’s final fall. ED was not aware of any modifications or any care plan changes for R1 after their falls. According to multiple staff interviewed (S1, S2 and S3), and the former Memory Care Director, the statements corroborated ED's statement regarding R1’s care plan not being updated after their falls, which included no definitive plan to update R1’s service plan for mitigating their falls. [CONTINUED ON LIC9099-C] Based on the Department’s investigation of the above-mentioned allegations, the evidence obtained during staff and outside source interviews, and records reviewed, there is sufficient evidence to meet the preponderance of evidence standard and the above allegations are deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D page of this report. As at least one violation resulted in the injury of a resident, an immediate civil penalty is hereby assessed per Health and Safety Code 1569.49(c)(1) and attached on the LIC421IM. Additional civil penalties are under review by the Department and may be assessed at a later date. The report was discussed, a plan of correction was jointly developed, and an exit interview was conducted with Executive Director Thomas. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22) were provided at the conclusion of the visit and the signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 08-AS-20240322161610

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Sep 26, 2025

87464 Basic Services (f) Basic services shall… include (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal… This requirement was not met as evidenced by: Based on record review and interview, the Licensee did not put measures in place to protect one resident (R1) from falls, which resulted in serious injuries. This posed an immediate health, safety and personal rights risk to 1 of 100 residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: Licensee agrees to schedule an in-service training on the topics of fall risk prevention and send proof of scheduling to the Department by 9/26/2025. Licensee agrees to send sign-in sheet and training topics to the Department by 10/23/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Sep 26, 2025

87465 Incidental Medical and Dental (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… This requirement was not met as evidence by: Based on interview and record review, staff did not arrange emergency medical care for one resident (R1) who was experiencing severe pain. This posed an immediate health, safety and personal rights risk to 1 of 100 residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: Licensee agrees to schedule an in-service training on the topics of seeking timely medical care and send proof of scheduling to the Department by 9/26/2025. Licensee agrees to send sign-in sheet and training topics to the Department by 10/23/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Oct 23, 2025

87466 Observation of the Resident The licensee shall ensure that residents are… observed… When… deterioration of…. mental ability or a health condition are observed, the licensee shall ensure that such changes are documented and brought to… the … physician and… responsible person… This requirement was not met as evidenced by: Based on record review and interview, staff did not inform one resident’s (R1) doctor or responsible when they experienced a change in condition. This posed a potential health, safety and personal rights risk to 1 of 100 residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: Licensee agrees to schedule an in-service training on the topic of documenting change in conditions and send sign-in sheet and training topics to the Department by POC date of 10/23/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Oct 23, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency … (1) A written report… to the licensing agency and to the person responsible for the resident within seven days of the occurrence of… (B) Any serious injury… occurring while the resident is under facility supervision. This requirement was not met as evidenced by: Based on record review the Licensee did not report a serious incident for one resident (R1) within 7 days. This posed a potential health, safety and personal rights risk to 1 of 100 residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: Licensee agrees to schedule an in-service training on the topic of reporting and send sign-in sheet and training topics to the Department by POC date of 10/23/2025.

Allegation investigated: Staff did not handle resident with dignity Staff yelled at resident

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced visit to initiate and deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Johnathan Thomas. On September 8, 2025, it was alleged that staff did not handle residents with dignity and staff yelled at residents. It was alleged that Staff #1(S1) abruptly pushed Resident #1 (R1) in their wheelchair and yelled at them while doing so. It was also alleged that R1 had been roughly handled by an unknown staff member previously as well. [See LIC811 Confidential Name List for identification of select person identifiers used in this report]. The Department’s investigation consisted of an unannounced facility visit, records review, and staff, resident, and outside source interviews. [CONTINUED ON LIC9099-C] Unsubstantiated Review of R1’s medical assessment records dated January 17, 2025, revealed that R1 had a diagnosis of dementia with behavioral disturbances, was confused/disorientated, and did exhibit inappropriate, sundowning, and aggressive behaviors. Also, according to R1’s medical assessment they required assistance with All Activities of Daily Living (ADLs) except for feeding themself and were non-ambulatory with a wheelchair. Due to R1’s baseline memory loss they were unable to be used as a reliable historian to aid in this investigation. Interviews and records reviewed did not reveal that S1 handled R1 in a rough manner nor did it reveal that any other staff member had handled R1 in a rough manner. Internal and external interviews did not reveal that S1 had yelled at or spoken inappropriately to R1. Based on interviews and records review, the investigation did not yield a preponderance of evidence to conclude that staff did not handle residents with dignity and staff yelled at residents. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director Thomas, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Sep 12, 2025 · control 08-AS-20250908111122

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Continuation Required Annual Inspection that was originally initiated on 4/11/2025. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Executive Director Johnathan Thomas. The facility's license shows a maximum capacity of one hundred twenty-five (125) non-ambulatory residents, fifteen (15) of whom may be bedridden. Hospice waiver for fifteen (15) and the facility is approved for delayed egress on the first floor. During today’s inspection there were one hundred (100) residents in care. During today’s visit, LPA with Executive Director Thomas toured the interior and exterior of the facility, and inspected a sample of rooms. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Executive Director Thomas, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. No deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Thomas to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Sep 12, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted by, identified themselves to and discussed the purpose of the visit with Business Office Director Reika Marron & Memory Care Director Daisy Rodriguez. The facility's license shows a maximum capacity of one hundred twenty five (125) non-ambulatory residents, fifteen (15) of whom may be bedridden. During today’s inspection there were one hundred three (103) residents in care. During today's visit, LPA reviewed facility records and took a brief tour of the facility. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. No deficiencies were cited on today's date. An exit interview was conducted with Business Office Director Reika Marron, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Apr 11, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Case Management visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Johnathan Thomas. Today's visit was in response to a self reported incident that occurred on 12/12/2024 regarding a medication error for Resident #1 (R1). [See LIC811 Confidential Names List.] During today’s visit LPA conducted a brief facility tour, reviewed facility records, and interviewed relevant staff. No deficiencies were cited during today’s visit. An exit interview was conducted with Executive Director Johnathan Thomas, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jan 2, 2025

Allegation investigated: Staff do not ensure that resident's hygiene needs are being met Facility is malodorous Staff do not assist residents to dinning hall Untrained staff providing care and supervision Staff handle residents in a rough manner

Licensing Program Analyst (LPA) Ryan Fulton and Licensing Program Manager (LPM) Jennifer Lott conducted an unannounced subsequent visit to deliver findings regarding the above allegation(s). LPA/LPM were welcomed by, identified themselves to, and discussed the purpose of the visit with Resident Services Director Sonia Molina. The Department's investigation consisted of LPA observations, interviews with facility staff, residents, and outside sources, as well as records reviews. It is alleged that staff do not ensure that resident's hygiene needs are being met. Specifically, it was alleged that R1 was left in soiled sheets and that staff were applying too much gel to R1's hair. R1, is visually impaired and requires assistance with toileting. (Continued on LIC9099C) Unsubstantiated However, staff interviews revealed that staff provide regular assistance with toileting. Interviews also revealed that resident’s sheets are changed immediately if they become soiled, otherwise sheets are changed by housekeeping staff weekly. 5:5 staff interviewed stated that they have not assisted R1 with putting gel in their hair. Resident interviews revealed that staff are meeting their hygiene needs, including changing soiled clothing and sheets when needed or at a minimum, once a week when housekeeping cleans the resident’s rooms. Residents interviewed expressed no concern with the level of hygiene care provided by the facility staff. Based on staff and resident interviews, this allegation is unsubstantiated. It is also alleged that the facility is malodorous. It was reported that the facility had feces and urine on the carpets in the public areas and that resident's rooms smelled of feces and urine. LPA conducted a tour of the facility on four separate occasions and did not observe any fecal matter or urine in the public areas. LPA also conducted a tour of 8 different resident rooms and found the rooms to be clean and sanitary. At no time during the LPA’s visits, did they encounter malodors. Interviews with staff and residents corroborated the cleanliness of the common areas and resident rooms. Based on interviews with staff, residents and LPA observations, this allegation is unsubstantiated. It was alleged that staff do not assist residents to dining hall. Interviews with staff and residents revealed that when residents make a request to go to the dining hall, staff provide assistance. Resident interviews revealed that staff arrive timely and provide stand assist or will push them in their wheelchair. Additionally, on 07/02/2024, 10/23/2024, and 01/22/2024, during unannounced facility visits, LPA observed staff assisting residents to the dining hall. Based on staff and resident interviews, along with LPA’s own observations, this allegation is unsubstantiated. It was also alleged that untrained staff were providing care and supervision. A records review from a random sampling of 8 staff members revealed that all staff have received adequate training through Relias. In addition, staff also receive additional hands-on training for a minimum of 1 week shadowing an experienced caregiver before being released to work independently. Interviews with staff also revealed that each staff member receives an additional 20 hours of training annually. Interviews with staff and residents confirmed they were able to meet resident’s needs. Based on records review, staff interviews, this allegation is unsubstantiated. (Continued on LIC9099C) Lastly, it was alleged that staff are being rough with residents in care. It was reported that staff do not know how to properly remove a resident's shirt while providing assistance with dressing. Interviews with residents revealed that staff were gentle in the assistance being provided. Staff interviews revealed that training had been provided on how to change resident clothing. Outside source interviews confirmed the staff training. Based on records review, staff resident and outside source interviews, this allegation is unsubstantiated. This agency has investigated the complaint allegations, staff do not ensure that resident’s hygiene needs are being met, facility is malodorous, staff do not assist resident to dining hall, untrained staff providing care and supervision and staff handle residents in a rough manner. The Department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations occurred. Therefore, the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted, and the report was along with licensee appeal rights (LIC 9058 03/22) reviewed with Resident Service Director Sonia Molina.the state’s words, verbatim · CDSS document, Nov 27, 2024 · control 08-AS-20240625130417

Allegation investigated: Staff do not ensure that resident's hygiene needs are being met Facility is malodorous Staff do not assist residents to dinning hall Untrained staff providing care and supervision Staff handle residents in a rough manner

Licensing Program Analyst (LPA) Ryan Fulton and Licensing Program Manager (LPM) Jennifer Lott conducted an unannounced subsequent visit to deliver findings regarding the above allegation(s). LPA/LPM were welcomed by, identified themselves to, and discussed the purpose of the visit with Resident Services Director Sonia Molina. The Department's investigation consisted of LPA observations, interviews with facility staff, residents, and outside sources, as well as records reviews. It is alleged that staff do not ensure that resident's hygiene needs are being met. Specifically, it was alleged that R1 was left in soiled sheets and that staff were applying too much gel to R1's hair. R1, is visually impaired and requires assistance with toileting. (Continued on LIC9099C) Unsubstantiated However, staff interviews revealed that staff provide regular assistance with toileting. Interviews also revealed that resident’s sheets are changed immediately if they become soiled, otherwise sheets are changed by housekeeping staff weekly. 5:5 staff interviewed stated that they have not assisted R1 with putting gel in their hair. Resident interviews revealed that staff are meeting their hygiene needs, including changing soiled clothing and sheets when needed or at a minimum, once a week when housekeeping cleans the resident’s rooms. Residents interviewed expressed no concern with the level of hygiene care provided by the facility staff. Based on staff and resident interviews, this allegation is unsubstantiated. It is also alleged that the facility is malodorous. It was reported that the facility had feces and urine on the carpets in the public areas and that resident's rooms smelled of feces and urine. LPA conducted a tour of the facility on four separate occasions and did not observe any fecal matter or urine in the public areas. LPA also conducted a tour of 8 different resident rooms and found the rooms to be clean and sanitary. At no time during the LPA’s visits, did they encounter malodors. Interviews with staff and residents corroborated the cleanliness of the common areas and resident rooms. Based on interviews with staff, residents and LPA observations, this allegation is unsubstantiated. It was alleged that staff do not assist residents to dining hall. Interviews with staff and residents revealed that when residents make a request to go to the dining hall, staff provide assistance. Resident interviews revealed that staff arrive timely and provide stand assist or will push them in their wheelchair. Additionally, on 07/02/2024, 10/23/2024, and 01/22/2024, during unannounced facility visits, LPA observed staff assisting residents to the dining hall. Based on staff and resident interviews, along with LPA’s own observations, this allegation is unsubstantiated. It was also alleged that untrained staff were providing care and supervision. A records review from a random sampling of 8 staff members revealed that all staff have received adequate training through Relias. In addition, staff also receive additional hands-on training for a minimum of 1 week shadowing an experienced caregiver before being released to work independently. Interviews with staff also revealed that each staff member receives an additional 20 hours of training annually. Interviews with staff and residents confirmed they were able to meet resident’s needs. Based on records review, staff interviews, this allegation is unsubstantiated. (Continued on LIC9099C) Lastly, it was alleged that staff are being rough with residents in care. It was reported that staff do not know how to properly remove a resident's shirt while providing assistance with dressing. Interviews with residents revealed that staff were gentle in the assistance being provided. Staff interviews revealed that training had been provided on how to change resident clothing. Outside source interviews confirmed the staff training. Based on records review, staff resident and outside source interviews, this allegation is unsubstantiated. This agency has investigated the complaint allegations, staff do not ensure that resident’s hygiene needs are being met, facility is malodorous, staff do not assist resident to dining hall, untrained staff providing care and supervision and staff handle residents in a rough manner. The Department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations occurred. Therefore, the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted, and the report was along with licensee appeal rights (LIC 9058 03/22) reviewed with Resident Service Director Sonia Molina.the state’s words, verbatim · CDSS document, Nov 27, 2024 · control 08-AS-20240625130417

Allegation investigated: Staff did not respond to resident's call button in a timely manner.

Licensing Program Analysts (LPAs) Ryan Fulton and Arian Golbakhsh, along with Licensing Program Manager (LPM) Jennifer Lott, conducted an unannounced subsequent visit to deliver findings regarding the above allegation(s). LPAs/LPM were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Johnathan Thomas. The Department's investigation consisted of LPA observations, interviews with facility staff, residents and outside sources as well as records reviews. It was alleged that on or about 02/03/2024, that staff did not respond to the resident's call button in a timely manner. Interviews conducted with staff revealed that all call pendant response times should not exceed ten minutes. Facility records revealed that during the timeframe of 01/22/2024 to 02/05/2024, the staff response times on 76 occasions, exceeded 20 minutes. Interviews and records revealed that most staff shortages took place during the early morning to mid-morning hours. (Continued on LIC9099C) Substantiated Outside source and resident interviews corroborated wait times in excess of 20 minutes even stating at times waiting up to 30 minutes for assistance. The Department has investigated the complaint alleging staff did not respond to resident’s call button in a timely manner. Based on LPA’s review of facility files, staff and outside source interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are cited per California Code of Regulations, Title 22, Division 6, on the attached LIC 9099-D. An exit interview was conducted and a copy of this report, LIC 9099D, along with Licensee/Appeal Rights (LIC 9058 03/22) was reviewed/provided to Executive Director Johnathan Thomas at the end of the visit.the state’s words, verbatim · CDSS document, Nov 22, 2024 · control 08-AS-20240308114025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Nov 22, 2024

PERSONNEL REQUIREMENTS – “…facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…” This requirement is not met as evidenced by: Based on LPAs interviews and record reviews, call button response times were in excess of 20 minutes on 76 different occasions during the period of 01/22/24 – 02/05/24. This poses a potential health and safety risk to 96 of 96 residents in care.the state’s words, verbatim · CDSS document, Nov 22, 2024

Plan of correction: Licensee will conduct inservice training with Staff in morning, after noon, and NOC shift and sign in sheets will be emailed to LPA on 12/13/2024.

Allegation investigated: Staff do not provide adequate food service for residents

Licensing Program Analyst (LPA) Ryan Fulton conducted an unannounced 10-day visit to initiate a complaint investigation and deliver findings regarding the above mentioned allegation. LPA introduced himself and disclosed the purpose of the visit to Executive Director Gregory Case. On 07/09/2024, it was alleged that staff did not provide adequate food service for residents. The department investigation consisted of LPA observations, interviews with facility staff, residents, and records reviews. The investigation revealed that during the timeframe of the complaint, staff provided adequate food service. LPA observed food offerings and determined that food was in good quality. Interviews revealed that food deliveries have no been of poor quality. Staff indicated that they have all been sufficiently trained in food safety and are continuously trained throughout their careers. Staff informed that food is ordered regularly and checked for freshness before it is received from the food vendor. Staff interviews revealed that when a food item expires, it is dealt with immediately, and staff do daily food safety checks to ensure that all food items are fresh. (Continued on LIC9099C) Unsubstantiated Resident interviews informed that the dining staff provides adequate food service to residents. Residents' interviews did not corroborate the allegation. Residents confirmed that the food acquired from the facility kitchen was of good quality and was made to their liking. Resident interviews did not raise any concerns about the ability of the kitchen staff. A review of facility records indicated that facility staff had adequate training. This training involved working on the floor with a more experienced serving staff and engaging in online training for food safety. The records review also showed adequate staffing for the dining area. LPA observations revealed that all food in the walk-in cooler was of good quality. LPA also observed that food items had expiration dates clearly posted on items in the refrigerator and the dry food area of the kitchen. LPA observed many items in the refrigerator, including blueberries, apples, oranges, cooked penne pasta, romaine lettuce, strawberries, iceberg lettuce, eggs, ranch dressing, and cheese. LPA observed daily menus on each dining room table indicating what food items were available for that day. LPA also observed residents' food items at the dining tables. Every plate that was observed looked to be of good quality. This agency has investigated the complaint alleging Staff do not provide adequate food service for residents. The department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred, therefore the above allegation is found to be UNSUBSTANTIADED. An exit interview was conducted, and report was reviewed with the licensee/facility representative.the state’s words, verbatim · CDSS document, Aug 21, 2024 · control 08-AS-20240709132740

Allegation investigated: Staff do not provide adequate food service for residents

Licensing Program Analyst (LPA) Ryan Fulton conducted an unannounced 10-day visit to initiate a complaint investigation and deliver findings regarding the above mentioned allegation. LPA introduced himself and disclosed the purpose of the visit to Executive Director Gregory Case. On 07/09/2024, it was alleged that staff did not provide adequate food service for residents. The department investigation consisted of LPA observations, interviews with facility staff, residents, and records reviews. The investigation revealed that during the timeframe of the complaint, staff provided adequate food service. LPA observed food offerings and determined that food was in good quality. Interviews revealed that food deliveries have no been of poor quality. Staff indicated that they have all been sufficiently trained in food safety and are continuously trained throughout their careers. Staff informed that food is ordered regularly and checked for freshness before it is received from the food vendor. Staff interviews revealed that when a food item expires, it is dealt with immediately, and staff do daily food safety checks to ensure that all food items are fresh. (Continued on LIC9099C) Unsubstantiated Resident interviews informed that the dining staff provides adequate food service to residents. Residents' interviews did not corroborate the allegation. Residents confirmed that the food acquired from the facility kitchen was of good quality and was made to their liking. Resident interviews did not raise any concerns about the ability of the kitchen staff. A review of facility records indicated that facility staff had adequate training. This training involved working on the floor with a more experienced serving staff and engaging in online training for food safety. The records review also showed adequate staffing for the dining area. LPA observations revealed that all food in the walk-in cooler was of good quality. LPA also observed that food items had expiration dates clearly posted on items in the refrigerator and the dry food area of the kitchen. LPA observed many items in the refrigerator, including blueberries, apples, oranges, cooked penne pasta, romaine lettuce, strawberries, iceberg lettuce, eggs, ranch dressing, and cheese. LPA observed daily menus on each dining room table indicating what food items were available for that day. LPA also observed residents' food items at the dining tables. Every plate that was observed looked to be of good quality. This agency has investigated the complaint alleging Staff do not provide adequate food service for residents. The department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred, therefore the above allegation is found to be UNSUBSTANTIADED. An exit interview was conducted, and report was reviewed with the licensee/facility representative.the state’s words, verbatim · CDSS document, Aug 21, 2024 · control 08-AS-20240709132740

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Gregory Case. Today's visit was in response to a licensee self-reported medication error. An Unusual Incident Report was received at the CCLD San Diego Regional Office on 05/17/2024. [See LIC 811 Confidential Names List for a description of residents]. Per the self-reported document, on 05/10/24 during the evening shift, nine (9) residents missed their medications due to staff inability to meet the two hour time frame of medication assistance. During today’s visit, LPA performed a brief welfare check on residents, finding no safety concerns. LPA interviewed Executive Director Gregory Case and Regional Clinical Specialist Joanne Gomez regarding the incident. A facility internal investigation was conducted and it was concluded that the error occurred due to the facility experiencing a shortage of staff. Immediately after the incident, all of the residents’ Primary Care Physicians and Responsible Parties were informed. No resident experienced adverse effects from the error. The facility implemented a plan to hire extra Med Tech staff as back-up. The facility also conducted an in-service training on proper medication management procedures for all staff responsible for handling medications. One (1) deficiency was cited per California Code of Regulations, Title 22, (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the Executive Director. An exit interview was conducted with Gregory, whose signature below confirms receipt of a copy of this report, the LIC811 and the Licensee Rights (LIC 9058 01/16).the state’s words, verbatim · CDSS document, May 23, 2024

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

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on records and interviews, the licensee did not ensure that 9 of 24 residents were assisted as needed with self-administration of prescription medications on 05/10/24, which posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, May 23, 2024

Plan of correction: The licensee conducted an in-service training with staff on 05/16/24 on proper medication management protocols. The licensee has also hired new Med Tech staff as back-up for emergencies.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Gregory Case. Today's visit was in response to an LIC624 Incident Report, which Licensee self-submitted to the CCLD San Diego Regional Office (received on 02/09/2024). The LIC624 described a medication incident involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of R1.] During today’s visit, LPA performed a brief facility tour and welfare check on R1, finding that they were alert, safe, and feeling well. LPA interviewed R1, outside sources, and relevant staff. LPA also collected copies of and reviewed patient care and medical records. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Case, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Mar 27, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Gregory Case. Today's visit was in response to two (2) LIC624 Incident Reports, which Licensee self-submitted to the CCLD San Diego Regional Office (both were received on 02/09/2024). According to the LIC624s: On 02/06/2024, facility management first became aware of allegations of Staff #1’s (S1’s) mistreatment of residents. Specifically, it was alleged that S1 handled Resident #1 (R1) roughly during personal care and that S1 intentionally gave Resident #2 (R2) a cold shower. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. Upon receiving these allegations, Licensee immediately suspended S1’s employment pending further investigation. During today’s visit, LPA performed a brief facility tour and welfare check on select residents in care. LPA collected copies of and reviewed pertinent care and personnel records, as well as handwritten and signed statements from staff (which Licensee’s collected during its own internal investigation). LPA also independently interviewed multiple relevant staff. [CONTINUED ON LIC 809-C, 1 of 2] [CONTINUED FROM LIC 809] According to R1’s Facesheet and LIC602 Physician’s Report (dated 08/28/2023), R1’s diagnoses included Dementia and “hemiplegia and hemiparesis following cerebral infarction [i.e., stroke].” R1’s Service Agreement with Licensee (i.e., care plan) showed that they required assistance of two (2) staff with incontinence care and dressing, among other needs. According to R2’s Facesheet and LIC602 Physician’s Report (dated 07/24/2023), R2’s diagnoses included Dementia. R1’s Service Agreement with Licensee showed that they required staff assistance with bathing, among other needs. According to R3’s Facesheet and LIC602 Physician’s Report (dated 02/01/2023), R3’s diagnoses included Dementia and Insomnia. Records showed that R1 had lived at the facility since 06/04/2022, while S1 had worked at the facility since 12/07/2022. Staff interviews widely corroborated that R1 experienced limited flexibility in their legs due to their underlying condition. Sometime between late January and early February 2024, there was an occasion when S1 quickly/forcefully opened R1’s legs while they attempted to provide incontinence care to R1, causing R1 to cry out in pain. This was witnessed by Staff #2 (S2) the only other person in the room at that time. Staff #3 (S3) and Staff #4 did not witness the above incident, but each described a separate occasion where they witnessed S1 refuse to provide personal care to S1 (for which other facility staff had to step in to help S1). According to records and staff interviews, during the same general time frame: There was a day when S1 gave R2 a shower using cold water. After R2 yelled out in protest, S2 intervened to pause the shower until the water could be warmed up. The cold shower incident was witnessed by both S2 and S3. Lastly, there was a morning when S2 saw S1 exit R3’s bedroom. S1 told S2 that R3 refused to get up out of bed. When S2 went into R3’s bedroom, they found R3 curled up in bed cold, with their blankets on the floor and their bedroom window left open. S3 was on duty at the time, and while they did not personally enter R3’s bedroom, they corroborated that S2 expressed to them that same day their concern about what they witnessed. [CONTINUED ON LIC 809-C, 2 of 2] [CONTINUED FROM LIC 809-C, 1 of 2] Due to their baseline memory loss, R1, R2, and R3 were unable to be interviewed. Personnel records showed: S1’s employment at the facility was suspended starting 02/06/2024. S1’s employment was subsequently involuntarily terminated on the basis that Licensee’s investigation concluded S1 had participated in “Patient Abuse/Neglect.” Per records, Licensee reported the respective incidents involving S1 against R1 and R2 to CCLD, the local Long Term Care Ombudsman Program (LTCOP), local law enforcement, and those residents’ responsible persons (RPs), as was required. However, Licensee did not submit a written report to the Department describing the alleged incident involving S1 and R3, as was required, despite gaining constructive knowledge of this latter allegation on 02/06/2024. Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). Since one of the deficiencies is a repeat violation within a twelve (12) month period of time, a civil penalty of $250 was also assessed (refer to the LIC421-FC). Plan of Corrections were jointly developed with the Licensee. An exit interview was conducted with Case, to whom a copy of this report, the LIC 809-D, the LIC421-FC, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Mar 27, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Mar 28, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect,…punishment,…mental, physical…abuse.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee’s staff (S1) did not ensure that 3 of 87 residents (R1, R2, and R3) were free from neglect, punishment, and/or mental/physical abuse. This posed an immediate health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2024

Plan of correction: According to personnel records, R1’s last day of employment at the facility was 02/05/2024 and they will not return. This resolves the immediate risk. Licensee agreed to retrain all remaining staff on Resident’s Personal Rights (as articulated in form LIC613-C). Licensee agreed to E-mail the training sign-in sheet to LPA, by 04/26/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Mar 29, 2024

87211 Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified...(D) Any incident which threatens the welfare, safety or health of any resident." This requirement was not met, as evidenced by: Based on records and interviews, 1 of 87 residents (R3) had an incident which threatened their welfare, safety, or health, and Licensee did not submit a written report of the incident to CCLD and the residents’ responsible person within seven days. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2024

Plan of correction: On 02/15/2024, Licensee coordinated with the local Long Term Care Ombudsman to have its staff retrained on Mandated Reporting Requirements. Licensee agreed to submit a written report describing the incident between S1 and R3 to CCLD, LTCOP, and R3’s responsible person, by the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Nacole Patterson and Ryan Fulton conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by and discussed the purpose of the visit to Executive Director Gregory Case. The facility's license shows a maximum capacity of one hundred twenty five (125) non-ambulatory residents, 15 of whom may be bedridden. During today’s inspection there were 86 residents in care. LPAs and Executive Director Gregory Case toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Executive Director Gregory Case, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs interviewed staff and clients, and reviewed facility records. The files reviewed by LPAs contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Gregory Case to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 19, 2024

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Dang Nguyen and Juliana Barfield conducted an unannounced Case Management - Incident visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Interim Executive Director Becca Black. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (it was received on business day 01/22/2024). According to the LIC624: on 01/13/2024, Resident #1 (R1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of select person identifiers used.] Facility staff located R1 the same day, and returned them to the facility, unharmed. During today’s visit, LPAs performed a brief facility tour and welfare check on R1, verifying that they were indeed safe. LPAs also collected copies of and reviewed pertinent records and interviewed relevant staff. According to their latest LIC602 Physician’s Report (dated 07/19/2023), R1 was diagnosed with Dementia and their doctor determined that they were not able to safely leave the facility unassisted. The multiple care appraisals which Licensee performed on R1, since the time of their move in, corroborated these points. Due to their baseline memory loss, R1 was not able to serve as a reliable historian/interviewee for this case. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Staff interviews unanimously showed: Around midday on 01/13/2024, R1 entered the facility’s lobby and stated to Staff #1 (S1) and Staff #2 (S2) their intent to leave the facility on foot. S1 freely allowed R1 to leave, unescorted, via the front door. S2 witnessed this, had concerns about it, but did not correct/stop S1 from letting R1 leave. S2 subsequently conferred with other staff, who reinforced that R1 could not be out in the community by themselves. Staff then used vehicles to search for R1. S1 subsequently located R1 and returned them to the facility unharmed. During the incident, R1 was unsupervised for about a half hour. Staff interviews further showed: Following the incident, Licensee conducted an internal investigation which found that the root cause of the incident was “training” (i.e., S1 did not have a clear understanding of R1’s cognitive limitations and whether R1 was allowed to leave the facility unassisted). Licensee’s staff first told R1’s physician and responsible person (RP) of the AWOL incident on 01/17/2024, which was four days after the incident. Licensee did not send a copy of the written incident report to the RP, as was required to be done within seven days. Licensee’s submission of the written incident report to CCLD was also late. During records review, LPAs observed (and manager interview confirmed) that Licensee did not possess a written Absentee Notification Plan (or equivalent missing resident policy) for C1 or the other residents in care, as was required. Two (2) deficiencies were cited per California Code of Regulations, Title 22. One (1) deficiency was cited per California Health and Safety Code. (Refer to the attached LIC 809-D pages). Plans of Correction was jointly developed with the licensee. An exit interview was conducted with Black, to whom a copy of this report, the LIC809-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jan 24, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Feb 23, 2024

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 records and interviews, the licensee did not ensure facility personnel (S1) was competent in knowledge to provide the services necessary to meet the safety needs of 1 of 96 residents (R1), which posed a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 24, 2024

Plan of correction: Per staff interviews: On 01/18/2024, Licensee performed retraining and an elopement response drill for its direct care staff. Licensee agreed to create a reference binder (with photos) to be kept at the front desk, which will help staff differentiate between those residents who can and cannot leave unassisted. Licensee agreed to send LPA proof of the binder completion, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.317 · Plan of correction due date: Feb 23, 2024

1569.317 Absentee Notification Plan for Missing Residents: “Every residential care facility for the elderly…shall…develop and comply with an absentee notification plan…The plan shall include…a requirement that an administrator of the facility, or his or her designee, inform the resident’s authorized representative when that resident is missing from the facility…and the circumstances in which [they] shall notify local law enforcement.” This requirement was not met, as evidenced by: Based on records and interviews, licensee’s staff did not develop a written absentee notification plan, which posed a potential safety risk to 96 of 96 clients (C1 through Client #96) in care.the state’s words, verbatim · CDSS document, Jan 24, 2024

Plan of correction: Licensee agreed to write an Absentee Notification Plan/policy meeting the requirements of CA H&S Code 1569.317, and to train all its staff on it. Licensee also agreed to add a copy of said Absentee Notification Plan in the written record of care for every current and future resident. Licensee agreed to E-mail the Plan and the training sign-in sheet to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Feb 23, 2024

87211 Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified...(D) Any incident which threatens the welfare, safety or health of any resident." This requirement was not met, as evidenced by: Based on records and interviews, 1 of 96 residents (R1) had an incident which threatened their welfare, safety, or health, and Licensee did not submit a written report of the incident to CCLD and the person responsible for the resident within seven days of incident occurrence. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 24, 2024

Plan of correction: During today’s visit, Licensee E-mailed a copy of the LIC624 Incident Report to R1’s responsible person. Licensee agreed to utilize a third-party source to retrain pertinent facility managers on Regulation 87211 Reporting Requirements. Licensee agreed to E-mail LPA the training sign-in sheet, by the POC due date.