La Vida Real

Type of visit: Collateral

Licensing Program Analyst (LPA) Jose De La Cruz conducted an unannounced collateral visit to interview a resident in regards to an unrelated ongoing complaint investigation with another licensed facility. LPA gained access to the facility, identified himself, and met with Executive Director Kimberly Garcia to discuss purpose of today's visit. LPA's visit consisted on a safety check and interviewing resident. There were no deficiencies observed during today's visit. An exit interview was conducted with Executive Director Kimberly Garcia and a copy of this report along with Licensee/Appeal Rights (LIC9058) was provided to Executive Director Kimberly Garcia whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jun 12, 2026

Allegation investigated: Staff did not meet the resident's needs Staff did not follow physician's orders for resident Licensee did not notify responsible party of resident's condition

Licensing Program Analyst (LPA) Iby Strong contacted Executive Director Kimberly Garcia via telephone to deliver findings on the above-mentioned allegation. On July 22, 2022, Community Care Licensing (CCL) received a complaint alleging staff did not meet Resident 1s (R1) needs, staff did not follow R1’s physician orders and licensee did not notify responsible party of R1’s condition. During the investigation, the Department conducted interviews and reviewed facility records. According to the allegation on or about July of 2022, Resident 1 (R1) did not receive services identified by R1’s physician to include daily weight checks, continuous blood glucose monitoring and blood pressure monitoring. R1’s Physician Report dated 12/17/2021, does not show that R1 required any continuous monitoring and is able to dress, groom and care for own toileting needs. Interview with outside source established that facility may be conducting such monitoring but is not documenting such checks. Unsubstantiated It was also alleged that R1 was not being bathed or taken to dining room for lunch. Records collected revealed R1 was being taken to the dining room and provided some meals in room as requested by the resident. Interview with outside source could not confirm that R1 was not provided meals throughout the day. Interview with another outside source revealed that there was no evidence of no bathing such as body other. Lastly, it was alleged that R1 had a change in skin condition and it was not reported to responsible party. Records collected showed that as of April of 2022, R1’s responsible party and medical provider were notified of edema to the lower extremities. Records also show that the party responsible was present on July 6, 2022, when staff found four edemas to both lower extremities and R1 was treated with antibiotics later that day. Interview with outside source did not reveal any information that facility was not reporting changes to R1 with the party responsible. Based on interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058) were provided.the state’s words, verbatim · CDSS document, Jan 21, 2026 · control 08-AS-20220722144719

Allegation investigated: Staff did not assist resident in a timely manner, resulting in resident fall

Licensing Program Analyst (LPA) Iby Strong contacted Executive Director Kimberly Garcia via telephone to deliever findings on the above-mentioned allegation. On December 19, 2025, Community Care Licensing (CCL) received a complaint alleging staff did not assist Resident 1 (R1) in a timely manner, resulting in R1 sustaining a fall. During the investigation, the Department conducted interviews and reviewed records. Details of the allegation state that on December 17, 2025, R1 was not assisted timely in using the restroom and R1 attempted to use the bathroom independently which resulted in a fall. Resident 1’s, Physical Report dated June 30, 2025, shows R1 has a cognitive condition but can care for own toileting needs. Resident service plan from July 7,2025 reveals that R1 requires minimal assistance with toileting and uses incontinence pads and a walker. Unsubstantiated Facility surveillance reviewed revealed that at 6:49am on December 17, 2025, R1’s bedroom door was open and at 6:59am, R1 walked through going towards the common area without a walking aid and fell. At 7:01am, staff arrived to assist resident and assess. Interview with Executive Director revealed that R1 was sent out for a medical evaluation. Interview with outside source, established that they have no concern with the care R1 was and is currently receiving at the facility. Based on records and interviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 14, 2026 · control 08-AS-20251219101314

Allegation investigated: Staff did not properly dispose of resident's medication Staff did not respond to resident's call button in a timely manner

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to conclude a complaint investigation. LPA identified herself and discussed the allegation mentioned above with Executive Director, Kimberly Garcia. During the investigation the facility was briefly toured, records reviewed, interviewed staff, residents, and outside sources. It was alleged that staff did not properly dispose of resident's medication. It was reported a staff member/director was stealing medication intended for destruction. The facility has a live camera located in the medication room that points directly at staff destroying medications. Staff interviewed denied stealing or witnessing medications being stolen. Multiple facility staff members confirmed Narcotic medications are destroyed by the Nurse and Medication Technician (med tech). Routine medications are destroyed by a med tech and another med tech, or a med tech and the director of assisted living. Which indicated they are not following Title 22 Regulations that outlines the medications shall be destroyed by the administrator and another adult. Continued on LIC 9099C. Substantiated It was also alleged that staff did not respond to resident's call button in a timely manner. It was reported it takes 30-45 minutes for staff to respond to Resident #2 (R2). A review of R2’s call button response log for October 2025 indicated some response times from 30-40 minutes. A review of Resident #6 (R6)’s call button response log for October 2025 indicated some response times from 30-65 minutes. Staff were not responding to residents in a timely manner. Based on interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Kimberly Garcia whose signature below confirms receipt of these rights. It was also alleged staff are physically abusing residents. It was reported Resident #1 (R1) and Resident #2 (R2) were being physically abused by staff and sustained bruises. The residents interviewed denied being abused by staff. Residents admitted they had bruises but were not certain how they were sustained. Residents explained they bump into things and take medications that increase risk of bruising. However, they did not believe staff would hurt the residents. Staff denied abusing residents. It was also alleged staff do not have background clearances and are currently working at the facility. A review of Guardian indicated two individuals were “in process”, meaning the individuals were not eligible. LPA confirmed that only one (1) of the two (2) individuals were actively working at the facility. The Human Resources (HR) staff explained they do not allow individuals to work in the facility unless they are fingerprint cleared and associated to the facility. HR staff explained that the individual working, Staff #1 (S1) has been employed for over 15 years, reflected in Guardian as a permanent employee, and they had the Department of Justice clearance document dated 09/07/2010 on file. Staff #2 (S2) have not begun employment at the facility. HR explained that years ago they had a change within their system, and they believe there was a glitch in Guardian. HR staff stated they contacted Community Care Licensing and were advised that S1’s documents were no longer uploaded to Guardian, possibly due to system errors. HR was advised to re-fingerprint S1 and upload the documents to Guardian. S1 was re-fingerprinted and cleared on 11/14/2025 and re-associated to the facility. S1 was employed for over 15 years, had eligible clearance, and documented as a permanent employee. There have been multiple issues with the Guardian system, which the Department is overseeing. It was also alleged that staff improperly transfer residents causing bruises. Residents that require transfer assistance were Interviewed. Those residents confirmed they are being transferred by staff accordingly and have not sustained any bruises while being transferred. Staff interviews also confirmed residents are not sustaining injuries during transfers. The Director of Assisted Living explained some residents are on medications that can increase the risk of bruising, such as blood thinners. A review of staff records reflected the facility conducts Orientation training that must be completed prior to working independently with residents. Some of the orientation training topics are transfer and lifting, and use of mechanical lifts. The facility provides ongoing training on lift assistance. The facility’s last training on transfers was conducted and documented on 10/09/25. The facility staff are trained on how to lift and transfer residents without causing injury. Continued on LIC 9099C. It was also alleged staff are withholding resident's medications. It was reported Resident #1 (R1) and Resident #3’s (R3) medications were withheld. It was unknown which medications were being withheld. A review of both residents Medication Administration Records indicated medications were given as prescribed, none were withheld. Staff interviews stated medications were not withheld from residents. R1 and R3 were interviewed and confirmed they were receiving their medications as prescribed. It was also alleged staff did not provide the resident with clean bed linen. It was reported residents are sleeping on the mattress without a sheet. On 11/05/25, LPA observed multiple resident rooms. All rooms inspected had clean linen present on beds. Resident interviews confirmed they are provided with clean linen weekly and more if needed. Staff confirmed residents linens are laundered weekly and more if needed. Resident beds contained appropriate bedding. It was also alleged that staff did not obtain medical attention for resident in a timely manner. It was reported Resident #3 (R3) was in pain and grimacing, and the nurse on duty was contacted to assess R3. It was reported the nurse advised staff to dispense R3’s already prescribed pain medication and see if it took effect, instead of sending R3 out for evaluation. It was also reported that R3 went to the hospital and was diagnosed with a lumbar fracture. However, review of R3’s medical records indicated R3 was admitted to the facility with the lumbar fracture. R3 was interviewed and denied any delay in medical care and reported they were pleased with the facility and staffing. It was also alleged staff did not keep facility free of odors. It was reported odors were coming from the third and fourth floor trash rooms, the main floor restrooms and an odor from Resident #4 (R4). It was alleged R4 had a stage 2 wound that was infected causing an odor. R4 was not interviewed as they passed away. A review of R4’s records did not identify any stage wounds. R4 had minor wounds, but none were pressure injuries. Also, R4’s hospice records did not indicate any signs of infection. Outside source reported the third and fourth floors trash rooms had odors coming into the hallway due to the facility not emptying it on a regular basis. However, staff confirmed it’s emptied every shift. Also reported, the main floor bathroom had an odor emitting into the hallway. Continued on LIC 9099C. On 11/05/25 and 12/08/25, LPA observed the third and fourth floors and the main floor bathroom, there were no odors. Outside sources that visit the facility were interviewed and confirmed there were no odors. Staff interviewed also confirmed there were no odors on the third and fourth floor trash rooms and they are emptied each shift and more if needed. Staff have not witnessed any resident’s with odors such as signs of infection. Staff also stated the main floor bathroom is for residents and public use. It was also alleged that staff did not ensure the resident's oral hygiene care needs were met. It was reported Resident #5 (R5) had canker sores on/in their mouth caused by lack of oral hygiene. R5 was interviewed and denied having any canker sores. R5 stated staff assist with oral hygiene when needed. Outside source reported that R5’s family is involved with R5’s oral care but the family does not follow through. The facility’s role is to assist or arrange dental care. However, the facility was not aware that the family was not following through with dental care. Management stated they will discuss dental care with the family. Staff denied observing canker sores on R5’s mouth. Staff explained if a canker sore is identified, they will notify the nurse for an evaluation. It was also alleged staff did not maintain a comfortable temperature. On 11/05/25 and 12/08/25, LPA observed a comfortable temperature, along with different regulated thermostats. Some resident rooms were warm and some were cool. LPA interviewed those residents, and they explained they were cold and preferred to keep their room warm. The residents are able to control the temperature in their rooms. Interviews with residents revealed they were comfortable with the facility’s temperature. Staff interviews confirmed the facility keeps the temperature regulated. Staff also commented that the residents prefer it warm, so they ensure the residents are comfortable. Staff reported that resident’s family members also adjust the thermostats in the room as well as the residents. The facility temperature was maintained throughout the facility, but the residents have the right to set their thermostats to any temperature they prefer. The Executive Director explained that if a thermostat isn’t working properly and they’re aware, the maintenance staff will address it immediately. It was also alleged that staff are intoxicated while providing care to residents. Interviews with staff confirmed they are not intoxicated while working. Residents also confirmed that they have not witnessed staff being intoxicated at work. The Executive Director (ED) explained there were no reports of staff being intoxicated at work or witnessed. The ED stated they would not tolerate or allow that behavior from staff. Continued on LIC 9099C. Lastly, it was alleged that staff did not keep the residents rooms free from bed bugs. On 11/05/25, LPA toured the facility and did not observe any bed bugs. The ED confirmed the facility did not have bed bugs. Resident interviews also confirmed they have not witnessed any bed bugs. Residents did comment they’ve been bitten by the mosquitoes outside. Staff also confirmed there have been no reported or witnessed bed bugs. Staff explained that some residents have sliding screen doors or patio doors in their room that leads to outside. Some residents like to keep the door open or step outside. There are mosquitoes in the area, and the residents have gotten bitten by mosquitoes, especially during the summer. However, there were not reports of bed bugs or bed bug bites. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Kimberly Garcia whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Dec 22, 2025 · control 08-AS-20251027095532

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

Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on record review, the licensee did not respond to 2 out of 124 [R2;-R6] residents’ requests for assistance in a timely manner. Some residents waited more than 30 minutes for staff to respond to and restore pendants. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 22, 2025

Plan of correction: The Executive Director stated they will conduct In-Service training on response times and resetting the call button. Proof of training due by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(i) · Plan of correction due date: Jan 19, 2026

Incidental Medical and Dental Care. Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy...shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: Based on interviews, the licensee did not ensure the medications were destroyed by the Administrator for 121 out of 121 [R1;-R121] residents, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 22, 2025

Plan of correction: The Executive Director stated they will apply for a waiver for medication destruction to appoint staff to destroy medications. Waiver due by POC due date.

Allegation investigated: Lack of Supervision resulted in serious bodily injury. Facility charged resident for services not rendered.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Administrator Kimberly Garcia. On May 7, 2025, Community Care Licensing (CCL) received a complaint alleging lack of supervision resulted in serious bodily injury to Resident 1 (R1) (R1 – see LIC811 Confidential Names List) and R1 was charged for services not rendered. Physician’s Report dated March 28, 2025, states R1’s primary diagnosis is mechanical fall and is not able to leave facility unassisted. R1’s Service Plan dated April 7, 2025, established that R1 requires extensive assistance with ambulation and escorting to and from activities and meals while being considered a fall risk due to a history of falls. Details of the allegation state that on April 24, 2025, R1 left the facility unassisted, walked one mile and fell at a nearby supermarket which resulted in a fractured hip. Video surveillance collected revealed that R1 was observed leaving the facility at 1:40pm. Substantiated Interview with a witness revealed that R1 was found unaccompanied and on the ground of the supermarket parking lot at around 3:00pm. Records collected from emergency personnel show that on April 24, 2025, at 2:56pm, emergency personnel were contacted to assist on the scene for an elderly fall at the exact address of the supermarket. R1 progress notes revealed that at 3:30pm, R1’s responsible party contacted the facility to report R1’s fall which had resulted in a fractured hip. Interview with R1 established that R1 was regularly allowed to walk freely throughout the facility including the courtyard which leads to the main road with no physical barrier. Video surveillance also revealed that as R1 was walking out of the facility, both the Executive Director and the Business Office Manager were behind R1, but video did not reveal actions taken by either to prevent R1 from leaving. Interview with the Director of Assisted Living established that R1 was regularly allowed to walk the courtyard unescorted and direct staff supervision was not consistently provided. Medical records collected revealed that R1 was diagnosed with closed fracture of right hip status post fall. The Department received information that R1 died on September 12, 2025. Official Death Certificate established that primary cause of death was hypertensive and atherosclerotic cardiovascular disease with significant condition attributing to death but not resulting in the underlying cause given was remote blunt force injury with right hip fracture while place of injury was identified as a parking lot. It was also alleged that R1 was charged for services not rendered. According to R1’s signed admissions agreement, R1 was assessed at Care Level II. Admissions agreement defines Level Care II care as 61-120 points per day of assistance with personal assistance and care services and costs an additional $2100 per month. Within R1’s Health and Services Evaluation Results completed on April 7, 2025, R1 was assessed with a total of 114 points, identifying bathing at 16 points, grooming assistance at 15 points, dressing at 20 points, toileting at 30 points, ambulation/escorting at 25 points, meal consumption as 3 at points and special care at 5 points. Additionally, in R1’s Service Plan dated April 7, 2025, R1 requires extensive assistance and requires total assistance or wheelchair escort to and from activities, meals, etc. by one staff member. Interview with multiple staff revealed R1 is regularly allowed to walk the facility premises unassisted or monitored. Interview with R1 prior to death, revealed R1 received little to no assistance while living at the facility. Based on the information collected, R1 was assessed for services to meet their individual need and such services were not provided. Based on interviews conducted, review of records, including outside sources records, a preponderance of evidence exists to support the allegation lack of supervision resulted in R1 sustaining serious injury and R1 was charged for services not rendered by facility. The allegations are therefore substantiated. Two deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). The Department has determined this violation resulted in a serious injury to the resident in care. An immediate Civil Penalty of $500.00 is charged and is noted on the LIC421IM. Additionally, two repeat violations have occurred therefore two $250 Civil Penalties will be assessed on the LIC421FC Currently, according to Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of Community Care Licensing Division. An exit interview was conducted with Administrator, and a Plan of Correction was jointly developed. A copy of this report, LIC811, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Administrator Kimberly Garcia, signature on this form confirms receipt of documents.the state’s words, verbatim · CDSS document, Dec 19, 2025 · control 08-AS-20250507102306

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 20, 2025

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as in evidence: Based on interviews and record reviews the licensee did not provide R1 with supervision in 1 of 124 people in care which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 19, 2025

Plan of correction: Licensee states that after the incident, all care staff and receptionist received training on elopment. Licensee states they will attain certified outside sourced training for all staff in regards to elopement and will provide proof of scheduled training via email to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jan 2, 2026

87468.2 (a) ...residents in privately operated residential care facilities ... shall have all of the following personal rights: (4)To ...services that meet their individual needs and are delivered by staff that are sufficient in numbers... and competency to meet their needs. This requirement was not met as in evidence: Based on interviews and record reviews the licensee did not provide R1 with services that met their individual need in 1 of 124 people in care which posed an potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 19, 2025

Plan of correction: Licensee states they will provide certified outside source training for all staff in regards to meeting resident individual needs and will provide proof to LPA via email.

Allegation investigated: Staff did not ensure resident had enough liquids, resulting in dehydration Staff speaks inappropriately to resident Staff did not ensure resident's room is clean and sanitary Staff did not provide notice of planned activities

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation. LPA met with Executive Director, Kimberly Garcia and discussed the above mentioned allegations. During the investigation, the facility was briefly toured, records reviewed, interviews conducted with staff, residents, and outside sources. It was alleged that staff did not ensure a resident had enough liquids, resulting in dehydration. Resident #1 (R1) Physician's Report dated 08/21/24 indicated R1 was Ambulatory and has a diagnosis of a Major Neurocognitive Disorder. It also indicated R1 was able to communicate needs, follow instructions, feed self, toilet, groom/dress, and bathe. It also stated R1 could administer their own inhaler. An outside source reported R1 was diagnosed with dehydration during a hospital visit on 09/22/25. A review of hospital records dated 09/22/25, reflected R1 went to the hospital regarding a medical condition. However, the medical condition was unrelated to dehydration. The documentation did not notate any dehydration for R1. Continued on LIC 9099C. Unsubstantiated R1 resides in the Assisted Living portion of the facility. R1 was alert and oriented when interviewed and ambulating well without assistance. R1 explained they were independent with their activities of daily living but required standby assistance with showers and medication management. R1 explained they do not like to drink water. R1 will drink iced tea from the dining room and fill their cup up and bring it back to their apartment. R1 explained that their family member attached a cup holder to R1’s walker and provided flavored packets for water. However, R1 doesn’t want to drink water. R1 explained they have the right to drink water/fluids when they feel like it. Staff interviewed confirmed they witness R1 drinking fluids but aware R1 doesn’t like water. It was also alleged staff speak inappropriately to residents. It was reported Staff #1 (S1) was rude to R1 by commenting “where do you think you're going!" when R1 was taking their dog for a walk. S2 denied speaking inappropriately to R1 and explained they look out for R1 and their small dog. Additional interviews with staff and outside source’s confirmed they have not witnessed S1 speaking inappropriately R1 or residents. It was also alleged that staff did not ensure resident's room is clean and sanitary. It was reported R1’s trash is not being emptied. Staff interviews identified the trash is removed/emptied each shift. Outside source interview indicated the trash will sit in R1’s room from Wednesday thru Saturday and emits odors. R1’s interview indicated the trash is removed/emptied daily. However, the trash is not emptied every shift on the weekends, but it will be emptied at some point during the weekend. Lastly, it was alleged that staff did not provide notice of planned activities. It was reported that the monthly calendar was not printed and made available for individuals. An outside source reported it occurred in October 2025, and the facility only provided the weekly calendars. LPA observed the monthly calendars are on the facility televised showing throughout the day, as well as posted in some common areas. The Executive Director explained there was a mix up and the calendars were not delivered. Therefore, they provided many more options available for residents and visitors review. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Kimberly Garcia whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Dec 8, 2025 · control 08-AS-20251114130250

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. LPA conducted the visit with Executive Director, Kimberly Garcia and Business Office Manager, Kristin Molina. LPA, accompanied by staff, 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. Resident bedrooms contained the required furnishings. Doors, windows and 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 resident activities. Hot water temperature at taps accessible to residents were all compliant and measured between 106-118 degrees F.. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. The facility's pool is located in the Independent Living portion of the facility and locked. There is a water fountain in the main front courtyard, which was empty and did not contain water. Per the Executive Director, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. The reviewed files contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Executive Director, Kimberly Garcia to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Dec 8, 2025

Allegation investigated: Licensee did not safeguard resident’s personal information Facility staff did not protect resident’s privacy

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to deliver findings on the above-mentioned allegations. LPA metBusiness Office Manager Kristin Molina and discussed the purpose of the visit. On December 22, 2021, Community Care Licensing (CCL) received a complaint alleging licensee did not safeguard resident’s personal information and facility did not protect resident’s privacy. During the investigation, the Department conducted interviews, and reviewed facility records. According to the allegation on December 20, 2021, a representative of Resident 1 (R1) received an unwarranted phone call regarding additional services to be paid for out of pocket by R1, though R1 or representative had not requested such services. Records from the Executive Director revealed that an outside source medical agency had been recently contracted to provide rehabilitation services to residents in care. Additional records show that such outside source medical agency had been providing services at the facility since November of 2021. Unsubstantiated It was also alleged that prior to the phone call mentioned above, R1 was visited in their room on two separate occasions by an unknown person and was asked for medical insurance documentation, making R1 feel like their privacy was violated. According to records collected, the unknown person was an employee of an outside source medical agency who was hired by the facility to provide rehabilitation services. Interview with outside source confirmed that outside source medical agency was only attempting to collect health insurance information to provide R1 with additional services. Based on interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Business Office Manager Kristin Molina, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Sep 5, 2025 · control 08-AS-20211222100718

Allegation investigated: Staff did not ensure resident is provided feeding assistance

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Business Office Manager Kristin Molina. On June 9, 2025, Community Care Licensing (CCL) received a complaint alleging staff did not ensure resident is provided feeding assistance. During the investigation, the Department conducted interviews, and reviewed facility records. According to the allegation Resident 1 (R1) was not being provided with feeding assistance as needed. Records collected revealed that R1 required extensive prompting throughout meals and may require assistance, additionally R1 has difficulty communicating needs. Interview with an outside source revealed that R1 was often found in room with food on lap or on the floor. Source also stated that it appeared R1 had not had any food assistance on multiple days. Substantiated Interview with R2 revealed that R2 has asked multiple times for assistance in eating and has waited up to thirty minutes for assistance. R2 also revealed that they must plead to staff to be taken to the dining room to eat as R2 does not want to be in room all day. Based on interviews conducted, review of records, including outside sources records, a preponderance of evidence exists to support the allegation. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Business Office Manager Kristin Molina Kristin Molina to whom a copy of this report, Appeals rights, LIC9099 C and LIC9099D were provided to. It was also alleged that staff did not ensure R1 was properly positioned in recliner and was often found slouched in recliner. Interview with outside source revealed that R1 had not been observed being left in recliner in slouching position for an extended period. Interview with staff revealed R1 was repositioned often. Based on interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Business Office Manager Kristin Molina, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Sep 5, 2025 · control 08-AS-20250609110429

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 19, 2025

87464 Basic Services.(f)Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as in evidence: Based on interviews and records reviewed the licensee did not provide assitance in feeding in 1 of 126 persons in care (R1) which posed a potential Health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 5, 2025

Plan of correction: Licensee states staffing has been adjusted as of July 2025 and will provide staff with inservice training regarding resident change in conditions. Licensee will provide LPA with training documentation by POC date.

Allegation investigated: Lack of supervision resulted in resident being left on the floor for an extended period.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Executive Director Kimberly Garcia. On October 3, 2022, Community Care Licensing (CCL) received a complaint alleging Lack of Supervision to Resident (R1) (R1 – see LIC811 Confidential Names List) resulted in R1 being left on the floor for an extended period. During the investigation, the Department collected records and conducted interviews. Physician’s Report dated March 22, 2021, confirmed R1 was diagnosed with a mild neurocognitive impairment and is ambulatory. R1’s Individual Service Assessment dated August 30, 2022, also established that R1 requires an escort and hand on assistance for mobility. Details of the allegation state that on September 28, 2022, R1 initiated their nighttime routine, and received medication from Medication Technician at 10:00pm. At about 10:30pm, R1 got up from their couch while using walker and fell sideways. Substantiated According to R1, R1 called out for help and could not reach their call pendant. R1 stated no one arrived to assist until about 7:30am on September 29, 2022. Interview with multiple training-staff revealed that staff are expected to check all assigned residents’ multiple times per night. Interview with responsible parties revealed that the facility advertised itself to them as checking in on assisted-living residents every two hours. Interview with Director of Assisted Living corroborated that facility staff are to check resident’s multiple times per night. According to records collected, the night of September 28, 2022, Staff 1 (S1) was assigned to R1’s floor. During an interview, S1 stated they did not check in on R1 the night of the incident and S1 had been told that R1 did not require continuous visual checks. Interview with Staff 2 (S2) established that on the morning of September 29, 2022, R1 did not call S2, as usual, for escort assistance to breakfast. S2 stated as they went to check on R1 they heard R1 yelling for help at about 7:10am, S2 stated that when they opened the door, they observed R1 in their room on the floor leaning against the patio door. S2 then proceeded to contact Staff 3 (S3) to assess R1 for injuries; no serious injury was found. Based on interviews and records collected, a preponderance of evidence exists to support the allegation. The allegation is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Kimberly Garcia, and a Plan of Correction was jointly developed. A copy of this report, LIC811, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to xxxxxx, signature on this form confirms receipt of documents. Details of the allegation state that on September 28, 2022, R1 initiated their nighttime routine, and received medication from Medication Technician at 10:00pm. At about 10:30pm, R1 got up from their couch while using walker and fell sideways. According to R1, R1 called out for help and could not reach their call pendant. R1 stated no one arrived to assist until about 7:30am on September 29, 2022. Interview with Staff 2 (S2) established that on the morning of September 29, 2022, R1 did not call S2, as usual, for escort assistance to breakfast. S2 stated as they went to check on R1 they heard R1 yelling for help at about 7:10am, S2 stated that when they opened the door, they observed R1 in their room on the floor leaning against the patio door. S2 then proceeded to contact Staff 3 (S3) to assess R1 for injuries. Interview with S3 established that S3 did a full body check of R1 and found no abnormalities. S3 stated that R1 did not express any pain and was given an as needed pain medication and an ice pack. Based on LPA's interviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director Kimberly Garcia to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 8, 2025 · control 08-AS-20221003100925

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 22, 2025

(a) residents in privately operated residential care facilities shall have all of the following...: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as in evidence; Based on interviews and records the licensee did not provide supervision and care to one resident in care (R1) of which posed a potential Health, Safety, and Personal Rights risk to persons in carethe state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: Licensee states they will conduct a re-training on resident monitoring by POC date.

Allegation investigated: Lack of Supervision resulting in physical abuse

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings for the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit with Executive Director Kimberly Garcia. On March 20, 2024, Community Care Licensing (CCL) received a complaint alleging lack of supervision resulted in physical abuse to Resident 2. During the investigation, the Department collected pertinent resident records as well as facility documentation and conducted interviews. Details of the allegation state that on March 18, 2024, Resident 2 (R2) was physically abused by Resident 1 (R1). According to Resident 1’s Physician Report, R1 is diagnosed with a major neurocognitive disorder as well as agitation and is aggressive. R2’s Physician Report states R2 is diagnosed with depression and heart failure but does not have any inappropriate behavior and is able to communicate need. Unsubstantiated According to records collected, R1 and R2 are a married couple. Interviews revealed that R2 reported the incident to staff who separated R1 and R2. Interview with an outside source confirmed that R1 and R2 were separated and put in different rooms after the incident. Interview with Executive Director revealed that responsible parties were not agreeable with the residents being separated. R1 and R2 were then returned to same bedroom and were later moved out of the facility by responsible parties. According to interviews with outside source, R1 did not have any history of aggressive behaviors. Based on interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 8, 2025 · control 08-AS-20240320105858

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced case management visit to follow-up on multiple incidents reported to Community Care Licensing. LPA introduced herself and discussed the purpose of the visit with Executive Director Kimberly Garcia. On August 6, 2025, Community Care Licensing received a self reported SOC341-Report of Suspected Dependent Adult/Elder Abuse forms in regards to an incidents involving Staff 1 (S1), and Resident 1 (R1). [LIC811 Confidential Names list to identify individuals]. According to the report, on an unreported date, R1 was having an aggressive episode and began to hit another unnamed resident. The report states it is alleged that S1 proceeded to forcefully control R1. Based on interview with Executive Director, there was not any additional information to prove S1 violated R1's personal rights. Between July 7, 2025 and August 7, 2025, the Department received twenty-five incident reports that were outside out the allotted time frame for reporting requirements. On August 6, 2025, the Department received an incident report from July 23, 2025, stating that R3 was not issued prescribed medication for 5 days after returning from the hospital. According to records, medication was prescribed July 19, 2025 and was initiated the night of July 23, 2025. On today's date, two deficiencies were issued. An exit interview was conducted with Executive Director Kimberly Garcia to whom a copy of this report, LIC809-D and Licensee Appeal Rights (LIC 9058) were provided to.the state’s words, verbatim · CDSS document, Aug 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 22, 2025

(a) (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as in evidence: Based on records and interviews the licensee did not assist resident with prescribed medication in one out of 126 (R1) persons in care which posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: Licensee states that medication training is scheduled for the following week and will provide LPA with documentation of such.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Aug 22, 2025

(a)... licensee shall furnish to the licensing agency... reports... including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. Based on records the licensee did not provide the licensing agency with twenty five incident reports within 7 days of occurrence in which posed a safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: Licensee states they will provide training to all staff that are reponsible for complete reporting documentation and will provide documention of such to LPA.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced case management visit. LPA introduced herself and discussed the purpose of the visit with Executive Director Kimberly Garcia. On today's date, LPA Strong delivered an Immediate Exclusion letter for Staff 1. Executive Director states she understands. No deficiencies were cited on today's visit. An exit interview was conducted with Executive Director Kimberly Garcia to whom a copy of this report, LIC809-D and Licensee Appeal Rights (LIC 9058) were provided to.the state’s words, verbatim · CDSS document, Aug 8, 2025

Allegation investigated: Staff had a verbal altercation with another staff in the presence of residents. Staff did not treat resident with dignity and respect

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to initiate a complaint investigation in the above-mentioned complaint allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Kimberly Garcia. On February 28, 2025, Community Care Licensing (CCL) received a complaint alleging residents witnessed a staff-on-staff verbal altercation and staff did not treat residents with dignity and respect. During investigation, LPA Strong collected pertinent facility records and conducted interviews. According to the first allegation, on an undisclosed date, Staff 1 (S1) and Staff 2 (S2) has an argument in the main lobby while residents were present. Interview with staff present on the date of the incident revealed that S1 and S2 had a discussion in the lobby but did not speak of any specific resident. Interview with S1 revealed that S2 did not appear to schedule work shifts, and such was being discussed as well as other S2 concerns relating to pasts incidents. Unsubstantiated Interview with S2 corroborated that S2 did have a discussion with S1 in the facility lobby regarding work shifts and incidents S2 had reported to management that had occurred at the facility. Also, interview with staff present established there were no other people in the lobby other than S1 and S2. Based on observations and interviews, S1 and S2 had the discussion in the unlicensed portion of the facility and the possible tenants present were from the independent living portion of the facility. It was also alleged that Staff 3 (S3) did not treat residents with dignity and respect as S3 made joking statements about resident’s incontinence needs, washed resident’s faces with cold water and rushed resident during care. During interview, S3 denied such allegations. Interview established that S3 was communicating resident needs to staff that were in training and incontinence information specific to a resident was necessary to provide proper care. S3 also stated that on one date, S3 could not get hot water to come out of one resident sink and wet a small corner of a washcloth into the water and used it to clean resident’s eyes. S3 states they did not wash the residents whole face with this water. S3 states that they do not rush residents during care. S3 revealed that residents in Memory Care require additional time and though S3 does not rush residents some residents do require prompting. Interview with other staff present on the date of the incident could not confirm that S3 made any of the statements or actions against residents. Interview with an outside source could not confirm that the alleged incidents occurred. Based on multiple interviews and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director Kimberly Garcia to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 7, 2025 · control 08-AS-20250228162841

Allegation investigated: Medication was not issued as prescribed Resident was charged for services not rendered

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above-mentioned complaint allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Kimberly Garcia. On February 11, 2025, Community Care Licensing (CCL) received a complaint alleging Resident 1’s (R1) medication was not issued as prescribed and R1 was charged for services not rendered. During investigation, LPA Strong collected pertinent facility records and conducted interviews. According to the first allegation, R1’s did not receive two medications as prescribed: metoprolol tartrate 25mg and Losartan Pot 25mg both requiring blood pressure to be measured prior to administration. Interview with former Director of Memory Care revealed that R1’s medication prescription was followed. Medication administration records corroborated that both above-mentioned medication was issued as prescribed and blood pressure was reviewed prior to issuing medication. Unsubstantiated Interview with Medication Technician revealed that R1 received medication as prescribed. Interview with outside source could not corroborate that medication was not issued as prescribed. It was also alleged that R1 was charged for services after September 30, 2024, though resident moved out on September 20, 2024. Records collected revealed that R1 was at the facility from September 7, 2024, until September 20, 2024. According to interviews, R1 submitted their 30-day notice on September 11, 2024, and had paid the full month of September of 2024. According to the reviewed Admissions Agreement, the resident continues to be responsible for all charges accruing under the agreement until 30 days. Based on such information, R1 is responsible for charges until October 11, 2024. Based on multiple interviews and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director Kimberly Garcia to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 7, 2025 · control 08-AS-20250211103925

Allegation investigated: Staff do not ensure residents call buttons are answered in a timely manner. Staff allow residents to be left in soiled clothing for extended periods of time.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to continue an investigation in the above-mentioned complaint allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Kimberly Garcia. On February 10, 2025, Community Care Licensing (CCL) received a complaint alleging staff do not answer call buttons in a timely manner and staff allow residents to be left in soiled clothing for an extended period. During investigation, LPA Strong collected pertinent facility records, conducted interviews, and completed a facility inspection. According to the first allegation, on February 9, 2025 at an undisclosed time, Resident 1 (R1) was requesting medication for pain and pressed their call button, after twenty minutes no staff appeared so family proceeded to find a Medication Technician to assist. Records collected revealed that R1’s button was pressed on February 9, 2025, one time at 3:00pm and not cleared by staff until 8:47pm. Unsubstantiated Interview with staff revealed that medication was issued to R1 when requested but the call button was not cleared by error. Medication administration records reviewed revealed that R1 was issued pain medication at 1:48pm and an anxiety medication at 2:59pm on the same date. According to pain medication prescription, medication can only be issued up to every two hours. Interview with an outside source did not confirm that R1’s call button was not answered in a timely manner. It was also alleged that staff allow R2 to be left in urine-soaked clothing for an extended period. On February 18, 2025, LPA Strong interviewed R2 and found that R2 can change own clothing and can go to the bathroom independently. Interview with staff revealed that R2 does not like using incontinence pads and often does not use them. Interview former Director of Memory Care revealed that R2 must be convinced to receive incontinence assistance and their bedding is changed multiple times per day. Records revealed that R2 is incontinent of the bladder/bowel. Based on multiple interviews and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director Kimberly Garcia to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. According to R1's Physician Report, R1 is diagnosed with a major neurocognitive disorder and has bowel and bladder incontinence. Based on observations and records reviewed, there is a preponderance of evidence that exists to prove licensee did not keep facility free of mal odors. Deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Kimberly Garcia, 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, Mar 7, 2025 · control 08-AS-20250210153551

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Mar 21, 2025

Managed Incontinence- b).... the licensee shall be responsible for the following (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.This requirement was not met as in evidence: Based on observations and records reviewed the licensee did not did not keep R1's room free of odors from incontinence in 1 of 120 persons in care which poses a potential personal rights risk.the state’s words, verbatim · CDSS document, Mar 7, 2025

Plan of correction: Licensee agrees to make R1's room clear of any urine odors by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Kimberly Garcia. According to the facility’s license, the facility has a maximum capacity of 177 non-ambulatory residents, of which 30 may be bedridden. The facility has an section of unlicensed independent living buildings on the west side of the property. LPA toured the interior and exterior of the facility and inspected seven rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Water temperature in residents rooms were measured all between 105 degrees F and 118 degrees F. Water temperature in common bathroom measured 115 degrees F. LPA toured and observed the commercial kitchen and walk-in freezer/refrigerator. Cooking/dining equipment and utensils were present. There was sufficient perishable food and at least two weeks worth of non-perishable food. LPA observed the medication room and first aids were complete and readily accessible. Medications were labeled, as required, and stored in locked medication carts. Resident records contained the required documentation. Staff records contained the required documentation. No pools or bodies of water on the licensed portion of the facility. Per Executive Director, no firearms or ammunition are kept at the facility. Fire extinguishers were readily accessible on each floor. No deficiencies were cited on todays visit. An exit interview was conducted with Executive Director Kimberly Garcia, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided to during the visit.the state’s words, verbatim · CDSS document, Dec 27, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced case management visit to follow-up on incidents reported to Community Care Licensing. LPA introduced herself and discussed the purpose of the visit with Assisted Living Director Yvonne Harmon. On September 30, 2024, Community Care Licensing received two self reported SOC341-Report of Suspected Dependent Adult/Elder Abuse forms in regards to two separate incidents involving Staff 1 (S1), Resident 1 (R1) and Resident 2 (R2). [Assisted Living Director was provided with an LIC811 Confidential Names list to identify individuals]. During today's visit, LPA conducted a health and safety check and collected records. An exit interview was conducted with Assisted Living Director Yvonne Harmon to whom a copy of this report and Licensee Appeal Rights (LIC 9058) were provided to.the state’s words, verbatim · CDSS document, Oct 1, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management visit. LPA met with Executive Director Kimberly Garcia, and discussed the purpose of the visit. Today's visit is in response to a self reported incident from the facility dated 9/20/2024. On 9/23/2024, CCLD received an SOC341 regarding Resident 1 (R1). The date of incident was 9/19/24, regarding alleged personal rights violation. On today's date, LPA conducted interviews and reviewed facility records. According to SOC341, R1 reported to Staff 2 (S2) that on the night of 9/19/2024, Staff 1 (S1) refused to assist resident in requesting medication for pain. Interview with R1 corroborated that S1 refused to assist and proceeded to take away R1's call button while using inappropriate language towards R1. Interview with multiple outside sources revealed that there have been previous instance of S1 being rude with other residents and taking R1's cellular phone away. Outside source confirmed that prior instances had been reported to previous Executive Director. Based on R1's Physician Report, R1 is diagnosed with a major neurocognitive disorder but is capable of communicating need and does not have any inappropriate or aggressive behaviors. Interview with current Executive Director revealed that S1 has since been separated from facility. At this time a preponderance of evidence exists to show S1 violated R1's personal rights. A deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). An exit interview was conducted with Executive Director, to whom a copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to.the state’s words, verbatim · CDSS document, Sep 27, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 11, 2024

87468.1(a)Residents.... shall have... the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons.This requirement was not met as evidence in that: Based on interviews the licensee did not accord residents with dignity in 3 of 120 #persons in care (R1, R2, R3) which posed a Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 27, 2024

Plan of correction: Licensee agrees to provide resident personal rights specifically to be accorded dignity in their personal relationships with staff by plan of correction date to LPA.

Allegation investigated: Facility staff failed to response to resident call button in a timely manner. Facility staff did not issue medication as prescribed.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to deliver findings in the above-mentioned allegations. LPA met with Executive Director Kimberly Garcia and discussed the purpose of the visit. On January 13, 2023, Community Care Licensing (CCL) received a complaint alleging staff failed to respond to resident call button in a timely manner and staff did not issue medication as prescribed. During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to allegation, on January 12, 2023, Resident 1 (R1) pressed their call button for assistance and staff took about one hour to respond. Call button records revealed that on the January 11, 2023, at 3:37pm R1 waited 82 minutes for assistance, on January 12, 2023, at 1:55pm R1 waited 21 minutes for assistance, then at 2:57pm R1 waited 40 minutes. Again, on January 14, 2023, R1 waited 46 minutes before being assisted. Interview with Assisted Living Director (ALD) revealed that staff are expected to respond to call buttons within 10-15 minutes. Substantiated Interview also revealed that R1 is a two person assist requiring additional staff per call, ALD explained R1 would need to wait for two staff to be available for assistance. It was also alleged that on January 12, 2023, at around noon, R1 requested medication for pain, which is prescribed as needed, but it was not provided to R1. Interview with Licensed Vocation Nurse (LVN) present on the date of incident revealed that they could not confirm that the medication was in fact given. Interview with Medication Aid (MA) present on the date of the incident revealed that they also did not issue the medication. Medication administration record revealed that R1 was not issued medication on January 12, 2023, until 9:30pm, when it was requested from another staff present. Medication prescription reviewed shows such pain medication may be administered as needed up to four doses per 24 hour period, there were no additional doses issued on this date. Based on interviews, and records reviewed, a preponderance of evidence exists to support the allegations. Deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Kimberly Garcia, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were providedthe state’s words, verbatim · CDSS document, Aug 28, 2024 · control 08-AS-20230113142615

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Sep 11, 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 was not met as evidence by: Based on interviews and records reviewed the licensee did not provide suffient staffing to respond timely to 1 of 65 persons in care [R1] which posed a potential Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 28, 2024

Plan of correction: Licensee is actively working on resident response time with carestaff and management. Licensee agrees to provide proof of action taken to LPA via email.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 11, 2024

87465 Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications. Based on interviews and records reviewed the licensee did not assist R1 with medication in 1 of 65 persons in care [R1] which posed a potential Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 28, 2024

Plan of correction: Licensee agrees to provide a training for medication to all care staff within two weeks and provide proof to LPA via email.

Allegation investigated: Neglect resulted in pressure injury Neglect resulted in resident sustaining falls Staff refused to provide resident with meals

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to initiate a complaint investigation on the above-mentioned allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Kimberly Garcia. On May 20, 2024, Community Care Licensing (CCL) received a complaint alleging neglect of Resident 1 (R1) resulted in a pressure injury, neglect of R1 resulted in falls and staff refused to provide R1 with meals. During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to R1’s medical records, R1 has a major neurocognitive impairment, can communicate need, is bedridden and requires assistance with toileting. According to allegation staff neglect has resulted in R1 having an undescribed pressure injury. Records collected revealed R1 does not have any current pressure injuries. Interview with outside medical source revealed R1 did have a pressure injury in December of 2023, but injury has since then healed. Unsubstantiated Outside source also revealed that R1 does have redness on back side but not enough to be considered a pressure injury. Interview with additional outside source did not reveal any information to corroborate that R1 neglect by facility staff has resulted in pressure injury. It was also alleged that R1 neglect has resulted in multiple R1 falls. Records collected revealed that R1 does have a fall risk. Interview with staff revealed R1 tends to move self-off of bed and onto the floor but does not fall. Records also revealed that R1 is checked-on multiple time throughout the day. Interview with outside medical source also corroborated that R1 tends to have episodes of agitations and puts themselves on the floor. Records and interviews did not reveal R1 has sustained any injuries from these incidents. Lastly, it was alleged that R1 has been fearful of staff not providing meals to R1. Interview with staff revealed R1 receives three meals per day. Interview with outside source established that outside source has not been informed of R1 not receiving meals. Records reviewed revealed that R1 has received multiple meals on today’s visit, May 29, 2024. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 29, 2024 · control 08-AS-20240520145305

Allegation investigated: Licensee did not provide resident's records to the authorized representative. Licensee did not reassess resident timely

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to initiate a complaint investigation on the above-mentioned allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Kimberly Garcia. On April 22, 2024, Community Care Licensing (CCL) received a complaint alleging Staff 1 (S1) did not provide authorized representative with Resident 1 (R1) records and licensee did not reassess R1 in a timely manner. During the investigation, LPA Strong collected pertinent resident records as well as facility documentation, conducted interviews and made observations. Based on Resident 1 (R1) Physician’s Report dated August 4, 2023, R1 is diagnosed with a Major Neurocognitive Disorder, is confused and disoriented, is depressed and can communicate needs. According to R1’s records, R1 moved into facility on July 31, 2023, was assessed on July 25, 2023, September 15, 2023, and March 21, 2024. Unsubstantiated According to allegation, R1’s authorized representative requested R1’s assessment in November of 2023 from S1 and had not received it. Records collected confirmed that responsible party had a digital copy of the September 15, 2023, assessment. Interview with S1 revealed that there were no additional requests made for medical records. Outside sourced interview revealed facility does not have a history of not providing records to residents or their authorized representatives. It was also alleged that R1 was not reassessed timely. Interview with S1 revealed that R1 was assessed in September of 2023, one month prior to request to be reassessed by an outside source. Interview with S1 also revealed that there were no significant changes noted to R1 requiring a new assessment at the end of 2023. Interview with S1 also revealed that R1 did have a social cognitive change in February of 2024. Records collected also established that R1 had a reassessment in March of 2024. Interview with outside source did not reveal any corroborating information that facility does not reassess residents timely. Based on interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director Kimberly Garcia, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 24, 2024 · control 08-AS-20240422093919

Allegation investigated: Licensee is harrasing resident.

Licensing Program Analyst (LPA) Iby Strong made an unannounced visit to continue an investigation on the above-mentioned allegation. LPA identified herself and disclosed the purpose of her visit. LPA met with Executive Director Kimberly Garcia. According to allegations, Resident 1 (R1) was harassed, by Staff 1 (S1), in an attempt to move R1 into a higher priced area of the facility. According to facility file review, facility has Community Care licensed assisted living and memory care with verified fire clearance capacity of 177 residents or 143 units. Facility also has an independent living non-licensed section of 210 units which totals 353 units combined. Based on R1 records, R1 resides in the independent living area of the facility in which Community Care Licensing does not have jurisdiction. Therefore, the complaint is unfounded. An exit interview was conducted and a copy of Licensee's Rights (LIC 9058 03/22) along with a copy of this report was provided to Executive Director Kimberly Garcia. Unfoundedthe state’s words, verbatim · CDSS document, Apr 24, 2024 · control 08-AS-20220629111515

Allegation investigated: Neglect/Lack of supervision resulted in injuries

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to initiate a complaint investigation on the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit with Executive Director David Armour. On February 13, 2024, Community Care Licensing (CCL) received a complaint alleging neglect of Resident 1 (R1) resulted in multiple injuries. During the investigation, LPA Strong collected pertinent resident records as well as facility documentation, conducted interviews and made observations. Based on Resident 1 (R1) Physician’s Report dated January 25,2024, R1 is diagnosed with a Major Neurocognitive Disorder, diabetes, is ambulatory and is known to have sundowning behavior. According to R1’s care plan R1 moved into facility on January 31, 2024, and requires minimal assistance with ambulating. Unsubstantiated According to allegation, on February 6, 2024, R1 was observed to have a large bruise on the front left side of head and well as bruises/scrapes on hands and arms. Interview with Director of Assisted Living revealed R1 had an unwitnessed fall on February 6, 2024. Interview established that R1 received first aid from Licensed Vocational Nurse and was taken to the emergency room, on the same day, when bruise developed on left side of face and head. Records collected revealed that R1 moved into facility with multiple bruises on arms. Interview with staff present on February 6, 2024, corroborated that R1 had an unwitnessed fall and was assessed for injuries. Interview with outside source did not reveal any information to corroborate neglect resulted in injuries. Finally, records collected established R1 was diagnosed with hypoglycemia on the date of the incident. Based on Department’s interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director David Armour, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 16, 2024 · control 08-AS-20240213091217

Type of visit: POC

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Plan Of Correction (POC) visit. The LPA introduced herself, and disclosed the purpose of the visit to Executive Director David Amour . During the visit, the LPA collected records, cleared POCs, and provided the administrator the Plan of Correction letter. An exit interview was conducted with Executive Director David Armour, to whom a copy of this report, and Applicant/Licensee Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Feb 6, 2024

Allegation investigated: Facility staff did not give medication as prescribed.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director David Armour. It was alleged that around April 2021 and May 2021, Licensee did not give Resident #1 (R1) their as-needed suppository (for treatment of constipation) as it was prescribed. Specifically, the complainant alleged the suppository was given too infrequently to address R1’s constipation needs. CCLD’s investigation involved an unannounced facility tour and welfare check on R1, review of R1’s pertinent facility care and hospice records, and interviews of relevant facility staff and outside sources. [CONTINUED ON LIC 9099-C] Unsubstantiated [CONTINUED FROM LIC 9099] According to R1’s prescribed medication orders: During the time-frame of the complaint, R1’s had only one medication which was in suppository form. R1’s doctor determined that this suppository could be given “rectally every day as needed for constipation, not to exceed one dose per 24 hours.” The prescription limited only the maximum amount to be given in a day; it did not specify a maximum number of days R1 could go without a bowel movement (BM) before the suppository was required to be given. According to the facility’s Medication Administrator Records (MARs): During April 2021, R1 was given the suppository once on 04/05/2021 (resulting in a medium BM), and once on 04/24/2021 (resulting in a large BM). During May 2021, R1 was given the suppository once on 05/04/2021 (resulting in a large BM), and once on 05/16/2021 (resulting in an extra-large BM). According to the facility’s Bowel Movement Logs: During April 2021, R1 had a total of 28 BMs, of which 23 BMs occurred on days when no suppository was given. On the two days when the suppository was given, R1 had not had a BM during the preceding four days. On all other days in April 2021, R1 had at least one BM every two days. During May 2021, R1 had a total of 24 BMs, of which 20 BMs occurred on days when no suppository was given. On the first day the suppository was given, R1 had not had a BM in the preceding three days. On the second day the suppository was given, R1 had not had a BM in the preceding two days. On all other days in May 2021, R1 had at least one BM every day, or every other day. According to R1’s LIC602 Physician’s Report (dated 10/15/2020): R1 was diagnosed with Alzheimer’s Disease. R1’s hospice agency records and facility care records corroborated this. Due to their baseline memory loss, R1 was unable to be a reliable historian/interviewee for this investigation. Based on record reviewed and interviews, a preponderance of evidence does not exist to prove that licensee did not give R1’s suppository as it was prescribed and needed by R1. The allegation is therefore unsubstantiated. An exit interview was conducted with Armour, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 10, 2024 · control 08-AS-20210528161206

Allegation investigated: Licensee did not have sufficient staff to meet resident care needs.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director David Armour. It was alleged that Licensee did not employ staff in sufficient numbers to meet Resident #1’s (R1) needs, because R1 called for help around 11:00 PM on a night in September 2021, facility staff did not respond to their call for help. [The complainant was anonymous and R1’s identity and room location were not made known to CCLD.] CCLD’s investigation involved an unannounced facility tour and welfare check on residents in care and interviews of relevant staff. The Department also reviewed the facility’s posted work schedules, employee timeclock logs, and electronic pull cord / call button log, among other records. [CONTINUED ON LIC 9099-C, 1 of 2] Substantiated [CONTINUED FROM LIC 9099] Per interviews of facility managers: The facility is divided into an Assisted Living (AL) section and a Memory Care (MC) section. The MC section is further subdivided into separate “J Court” and “M Court" buildings. The PM caregiver shift ends at 11:00 PM, and the overnight (NOC) caregiver shift starts at 11:00 PM. Around the time-frame of the allegation, there were 115 total residents in care. Based on those residents’ care acuity levels at that time: PM shift was considered safely staffed if there were at least four (4) caregivers in AL and at least four (4) caregivers in MC. NOC shift was considered safely staffed if there were at least three (3) caregivers in AL and at least three (3) caregivers in MC. NOC shift was also expected to have one (1) med aide on duty to share between AL and MC; this person was cross trained and able to cover caregiving duties, if needed. Outgoing staff were expected to verbally debrief their incoming counterparts (of shift happenings) in one-to-one conversation. According to caregiver work schedules: on the night in question, there were four (4) PM caregivers assigned to AL and four (4) PM caregivers assigned to MC. There were two (2) NOC caregivers assigned to AL and four (4) NOC caregivers in MC. Per these work schedules, Licensee had planned on meeting its caregiver staffing targets for PM and NOC shifts, at least at the net (facility-wide) level. However, employee timeclock records showed that there were a few staff whose actual timeclock entries deviated from their assigned work schedule, such that the facility was short-handed in specific sectors at specific times, which had a potential impact on resident health and safety. According to electronic timeclock records, which were read in concert with the caregiver work schedules: On the night in question, within the MC “J Court” Building, PM Caregiver Staff #1 (S1) clocked out at 10:56 PM and PM Caregiver Staff #2 (S2) clocked out at 10:57 PM. The early departure of S1 and S2 was not counteracted by either of their two “J Court” NOC relief caregivers starting work early [i.e., NOC Caregiver Staff #3 (S3) clocked in at 11:00 PM, and NOC Caregiver Staff #4 (S4) clocked in late at 11:05 PM.] Although there was one NOC Med Aide Staff #5 (S5) who was on duty at the time and able to cover caregiving tasks in AL, the result was that MC “J Court” was still short-handed by one staff during a brief time-period that was relevant to the complaint allegation. [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] On the night in question, within the AL Building: NOC Caregiver Staff #6 (S6) was 44 minutes late to work (i.e. clocked in at 11:44 PM). There was just one other NOC caregiver teammate, Staff #7 (S7), assigned to the AL building, instead of the usual two. While some PM staff lingered on duty beyond the end of their shift, the last PM staff person clocked out at 11:22 PM, rather than remaining on duty until S6 arrived. For the next 22 minutes, AL section was short-handed by at least one staff during a brief time-period relevant to the complaint allegation. Based on interviews and records, a preponderance of evidence exists to show that for a portion of the night in question, Licensee did not employ staff sufficient in numbers to meet a resident's care needs. The allegation is therefore substantiated. One (1) deficiency was 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 Armour, to whom a copy of this report, the LIC 9099-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 10, 2024 · control 08-AS-20210920145646

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Feb 9, 2024

87411 Personnel Requirements – General: “(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.” This requirement was not met, as evidenced by: Based on interviews and records, during the incident in question, Licensee did not ensure facility personnel were sufficient in numbers to provide the services necessary to meet the needs of 1 of 115 residents (R1), which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 10, 2024

Plan of correction: License agreed to retrain its current direct care staff on the following expectations: a) The posted shift end time is the time staff should physically depart the caregiving floor to walk to the timeclock, not the time staff clock out; b) The posted shift start time is the time staff should physically arrive on the caregiving floor after they have walked there from the timeclock; c) Shift leaders (i.e., nurses and med aides) should monitor for any late arrival notices from incoming staff, and ask for volunteers from the outgoing shift to stay on longer, if possible, until the late person arrives, particularly if the shift in that area is already running lean; and, d) Excessive occurrences of tardiness may warrant discipline according to company policy. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Director of Assisted Living Perla Provencal, after identifying herself and stating the purpose of the inspection. This facility serves one hundred and Seventy Seven (177) non- ambulatory elderly residents 60 and above; thirty (30) of whom may be bedridden. Hospice waiver approved for 24. A tour of the facility was conducted which included a sample of resident units, the dining area, recreation rooms, and food storage areas. There is a three-story complex with memory care on the first and second floor. PPE supplies are onsite. Passageways were free from obstructions. Facility does feature a locked perimeter on the first and second floor. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-C] Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed room not assessable to residents. Centrally stored medications were properly stored and locked in cabinets. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions. Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures and made recommendations. LPA conducted a review of In-service training procedures. Transportation procedures are compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. Based on LPA observation of resident’s rooms, licensee did not provide non- skid mats or strips in some room showers, which posed a potential health and personal rights risk to persons in care. A technical violation was also issued at today’s visit. 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 Director David Armour and Director of Assisted Living Perla Provencal. An exit interview was conducted with Director of Assisted Living Provencal to whom copies of this report, the LIC 809-D page, the LIC 9102TV, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of this visit..the state’s words, verbatim · CDSS document, Dec 29, 2023

Allegation investigated: Physicial abuse Resident sustained an unexplained fracture while in care. Resident's call button is not accessable.

Licensing Program Analyst Becky Kennedy concluded the investigation which began on 3/16/2021. LPA Kennedy made an unannounced visit to the above facility today and was greeted by Administrator, David Armour. LPA advised licensee of the reason for today's visit and delivered the investigation findings on the above allegations. Investigation consisted of observations, interviews with residents, staff, outside sources, records reviews, and tour of the interior and exterior facility. It was alleged that Resident 1 (R1) sustained a fracture on their hand as a result of physical abuse. Investigation revealed that R1 has both physical and mental health diagnoses including being blind, and with difficulty hearing. Unsubstantiated Or about January 8th, 2022, Witness 1 (W1) noted that there was an injury to R1’s left index finger. R1 reported to W1 that they ran their wheelchair into a wall crushing their finger. W1 asked Staff Member 1 (S1) to check R1’s hand. S1, who is a Licensed Vocational Nurse, recalled noticing some light bruising on R1’s hand about 5:00 PM. S1 moved the hand lightly and R1 did not report any pain. S1 did not document their assessment or elevate any concerns regarding R1. S1 reported that R1 slept through to 11:00PM, the end of S1’s shift, without complaint of pain, even when receiving care. On or about January 9th, 2022, W1 noticed an injury to R1’s right hand. On January 10th Staff Member 2 (S2) was getting R1 up for breakfast and noticed the bruising on R1’s hands and R1 was complaining of pain. Witness 2 (W2) came to the room already aware that R1 had injured hands. W2 transported R1 to the hospital about 10:30 AM. At about 5:30 PM R1 returned to the facility with a soft cast and a diagnosis of a metacarpal fracture to the right ring finger. The physician that treated R1’s hand injuries did not report any suspicion of physical abuse. During the course of the investigation, it was revealed that R1 reported multiple and incompatible explanations for their injured hands. The investigation included interviews with staff members who provide care for R1 and all report training and practices that would protect R1 from injuries, specifically to R1’s hands. It is unclear how R1 sustained the injuries. It was further alleged that the call button was not assessable to R1. Based on observation and interviews, there are always three call buttons in R1’s room. One in the bathroom, one in the living room and a portable call button in a box, generally kept on a table. R1 became agitated when the box with the call button was moved to a location, thought to be more accessible to R1. The call button was returned to the table per R1’s preference. There is insufficient evidence to conclude that R1 did not have access to a call button. Based on inconsistent statements, and the lack of evidence or witnesses to corroborate or support the allegations, the findings are unsubstantiated. An exit interview was conducted and a copy of this report, and appeal rights were given to Administrator, David Armour.the state’s words, verbatim · CDSS document, Dec 20, 2023 · control 08-AS-20220112123226

Allegation investigated: Facility call system was in disrepair Staff did not meet resident(s) incontinence needs.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Executive Director David Armour. On 11/15/2023 it was alleged that the facility's call system was in disrepair, and staff did not meet resident(s) incontinence needs. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, outside sources, and LPA direct observations. Regarding the allegation, "Facility call system was in disrepair", it was alleged that the call button system in resident rooms was broken, resulting in a delayed response from staff. Staff interview revealed that the system was in working order and the contractor for the call system was recently out to the facility for a routine check with no issues. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) Records review confirmed that the outside contractor came to the facility on 10/4/2023, upgraded and tested the system, with no issues noted. LPA directly observed and tested the call button system, revealing it to be in working order with no errors or glitches. Resident interview revealed that while residents sometimes observed a delay in the response time from staff, the call system worked correctly. Outside source interviews did not corroborate the allegation, informing that no disrepair issues have been observed with the call button system. Regarding the allegation, "Staff did not meet resident(s) incontinence needs", it was alleged that staff did not assist residents with incontinence care in a timely manner. Staff interviews did not corroborate the allegation, revealing that staff checked residents every 1-2 hours, per protocol, and as needed depending on condition and requests for assistance. Resident interviews were inconsistent; some residents stated they waited too long for help, while other residents stated they receive toileting assistance timely, when requested. Outside source interviews did not corroborate the allegation, and did not express concern regarding the time in which residents wait for incontinence assistance. Records review did not give evidence to support the allegation. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director David Armour, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 20, 2023 · control 08-AS-20231115162446

Allegation investigated: - Staff did not follow hospice care plans - Residents’ rooms were not kept clean - Staff did not provide clean linens - Staff did not maintain current resident records - Staff did not have required training

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings for a complaint investigation. LPA identified herself and was granted entry by Lyn Aquino, Receptionist. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director David Armour and Enliven Director Kristin Molina. The Department’s investigation consisted of interviews with staff, residents, and outside sources, records review of relevant documents pertinent to this investigation, and LPA observations. On October 27, 2023, it was alleged that staf did not follow hospice care plans. It was specifically alleged that the facility staff did not maintain resident’s #1 (R1) hospice file current. A separate file for residents who were under a hospice agency was maintained current, specifically for R1. R1’s hospice binder showed their initial hospice information and documents, but the current hospice agency information was included and updated with the hospice care plan located within that binder. Based on the information obtained, there is insufficient evidence to support the allegation. Unsubstantiated It was specifically alleged that residents’ laundry and trash bins were overflowing. A co-complainant later informed that there were blood stains on resident #2’s (R2) furniture. Interviews with residents said that staff walk throughout the building in the morning and throughout the day to pick up their trash. Normally it would be housekeeping staff who picked up their trash when they cleaned their rooms, but if they have trash to be taken out, residents would place it outside their doors and staff would ensure it is picked up. Interview with staff corroborated the residents’ statements. They have staff conduct their last rounds of morning trash pick-up. The Housekeeping Service Procedures specifically indicate what housekeeping services includes and trash removal was included. Interview with an outside source did not have any concerns. A review of records revealed that the residents have notices posted next to their front door advising them of their assigned housekeeping day including the numbers to the front desk areas. Housekeeping records showed that staff have assigned units and allotted timeframes to ensure each unit has been cleaned thoroughly. The Housekeeping Schedule showed the areas where staff were assigned during the week. There are Independent Living (IL) and Assisted Living (AL) Cleaning Days sheets that separate each floor by section assigned to specific housekeeping staff. Per the cleaning days sheet, staff are assigned approximately 8 rooms daily to clean. The Housekeeping Assignment Sheet log showed that housekeeping staff are in their assigned room(s) for approximately 45 minutes to one hour cleaning their assigned rooms for the day. On November 2, 2023, LPA toured the facility and was able to observe residents’ rooms at random throughout the facility. Each room displayed to be clean and sanitary. There were no trash or laundry that overflowed the residents’ bins. On November 17, 2023, LPA toured R2’s room and did not observe any blood on their furniture. Based on the information obtained, there is insufficient evidence to support the allegation. It was specifically alleged that staff did not provide residents with clean linens. Interviews with residents said that they are provided clean linens weekly or on an as needed basis. Residents had no issues with their linens being unclean. Residents said that they have an assigned laundry day that the care staff follow to launder their clothing. If they have the need to do an emergency wash, they notify the front desk and they will call staff to assist; or they also have the option if they want to launder their clothing themselves. Interview with staff corroborated their statements. Staff also said that caregivers are responsible for laundering the residents clothing by the end of their shift. If the laundry was not completed by the end of their shift, it would then be reassigned to the upcoming shift. (Continue on LIC9099-C) Interview with an outside source did not have any concerns. A review of records revealed that residents had a schedule posted in their room with specific housekeeping days that included contact numbers to their front desk area. In addition, on the bottom of the page of a posting on the residents’ wall was a bolded remark with many asterisk symbols that said to push their call button for assistance. Additionally, the memory care and assisted living care staff have a laundry schedule for each of their three shifts. The Care Staff Assignment sheet showed that staff signed responsibility for completing the tasks to their assigned unit(s) daily. On November 2, 2023, LPA toured the facility and observed that the residents’ linens were cleaned and in good repair. Based on the information obtained, there is insufficient evidence to support the allegation. It was specifically alleged that staff did not maintain residents records current with updated medical records in the residents’ files, specifically resident #1 (R1) and resident #2 (R2). A review of records revealed that the facility maintained a facility file for all residents. Medical records for R1 were current under their hospice binder. In review of R1’s file revealed that responsible party information was located within the file documents and the medical documents were current. A review of R2’s records revealed that their medical information, specifically their Physician’s Report (LIC602) was dated 7/5/22 and is in the process of obtaining a more current update report. A request dated 11/10/23 was sent to R2’s physician. Based on the information obtained, there is insufficient evidence to support the allegation. It was specifically alleged that staff did not have sufficient training prior to working independently. Interviews with staff said they do provide training online and hands-on training with their staff. According to Enliven Director, the facility provided training to their new employees upon hire. Depending on the experience of the new employee hire, they will provide them with their onboarding, online training, and have them shadow another staff, then release them for independent duties. Per Enliven Director, training ranged from 5 days of training for an experienced employee to three weeks for an employee to feel comfortable enough to be released to work independently. Per the Enliven Director, if staff still have questions they are able to ask co-workers after they are independently released. A review of staff training records revealed that the facility provided training to their staff upon hire. New employees completed training modules through either the facility’s internal training system (“classroom”) or hands-on (“shadowing”). Each training sheet was specific for each staff by their position of hire. Based on the information obtained, there is not enough evidence to support the allegation. (Continue on LIC9099-C) Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff, residents’ and outside source interviews, records reviewed, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Executive Director David Armour and Perla Provencal, Director of Assisted Living. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Armour at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Nov 17, 2023 · control 08-AS-20231027144405

Allegation investigated: - Facility did not maintain resident’s bathroom in sanitary condition

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to open a complaint investigation. While at the facility LPA investigated and delivered findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by Lyn Aquino, Receptionist. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director David Armour and Kristin Molina, Enliven Director. The Department’s investigation consisted of interviews with staff and outside sources, LPA observations, and records review of relevant documents pertinent to this investigation. On November 13, 2023, it was said that the facility did not maintain resident’s bathroom in a sanitary condition. It was specifically alleged that the facility staff did not replace resident #1’s (R1) lavatory cover timely that resulted in unsanitary conditions inside the tank. Interview with Maintenance Director said that they obtain about 30 work orders daily and about 1,100 work orders monthly. They categorize work orders based on emergencies. Substantiated There are 6 maintenance assistants who the work orders are assigned to by category (plumbing, electrical, etc.). The front desk reception area originates the work order’s through their internal system. When a work order is submitted, their system then sends out a signal to their work cellular phone informing them of a new work item. There may be times when unexpected occurrences transpire, and a work order may not be submitted through their internal system, but the work would still be completed. Interview with Enliven Director said that they were unaware that there was an issue with R1’s bathroom until they received a notice from the family about one week ago which was immediately addressed. According to the Executive Director, it took the facility about three days to ensure the toilet and the “worm” issues were addressed. A review of maintenance records revealed that a work order was submitted on or about September 7, 2023, for a toilet cover in R1’s suite to be fixed. There was only one work order specifically for R1’s toilet cover submitted in their internal system in the last six months. An email dated November 08, 2023, revealed that the toilet cover was still needed and the tank was in need to be sanitized due to worms. Video footage was made available and disclosed there were small worm-like insects inside the lavatory tank. On November 17, 2023, LPA toured the facility. During the tour, LPA entered into R1’s room and observed the toilet cover was fixed and there were no worms in R1’s lavatory tank. Based on the evidence obtained there is enough evidence to support the allegation. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside source interviews, records reviewed, and LPA observations, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099D. The report was discussed, plan of correction was jointly developed and cleared, and an exit interview was conducted with Executive Director David Armour and Perla Provencal, Director of Assisted Living. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director David Armour at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Nov 17, 2023 · control 08-AS-20231113095405

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 17, 2023

87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times… this requirement was not met as evidence by: Based on documentation, staff did not fix R1’s toilet tank cover timely resulting in worms breeding inside the tank. This posed a potential personal rights risk to 1 of 306 [R1] residents in care.the state’s words, verbatim · CDSS document, Nov 17, 2023

Plan of correction: Due to LPA observations during the visit, the POC has been cleared.

Allegation investigated: Staff did not assess residents after falls Staff did not ensure residents are protected against hazards.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to initiate a complaint investigation on the above-mentioned allegations. LPA identified herself and discussed the purpose of the visit with Executive Director David Armour. Memory Care Director Kristen Molina arrived shortly after. On November 6, 2023, Community Care Licensing (CCL) received a complaint alleging staff did not accurately assess resident after a fall and staff did not protect resident from hazards. During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to allegation, staff is going against facility policy and assisting residents after falls without prior consent of Licensed Vocational Nurse or Medical Technician (MedTech) on shift. Interviews with staff revealed that the facility has a policy for caregivers not to evaluate resident’s after falls rather contact nurse or MedTech on shift. Unsubstantiated Continuation from LIC9099 Interview with staff also revealed that caregivers have assisted residents after falls after conducting a basic assessment themselves. Interview with outside source did not reveal any information to corroborate facility is not assessing residents after falls. It was also alleged that Resident 1 (R1) had hazardous nightstand in their room, causing them injury. Interview with R1 revealed that R1 had a fall and hit head on nightstand causing a cut on the forehead. LPA Strong observed a standard wooden nightstand with pointed corners. Interview with outside source revealed that the furniture piece was not hazardous, rather R1 fell and in doing so hit the nightstand. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director David Armour, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.the state’s words, verbatim · CDSS document, Nov 9, 2023 · control 08-AS-20231106144709