Laguna Estates Senior Living

Allegation investigated: Staff are not assisting residents in a timely manner Staff did not ensure resident's room was clean

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director (ED) Brandon Cho. On 04/16/2026 it was alleged "Staff are not assisting residents in a timely manner." The Department’s investigation consisted of unannounced facility visits, interviews with residents, and records review. Regarding the allegation, "Staff are not assisting residents in a timely manner.", it was alleged facility staff members do not help residents who need assistance within a reasonable amount of time. In this case, as determined by the investigating LPA, a reasonable amount of time is no longer than fifteen to twenty (15-20) minutes. (Continued on LIC9099C, Page 2) Unsubstantiated Resident interviews revealed that residents do not normally wait an unreasonable amount of time to be helped by staff when they engage the signal system or the pendent alert system. Residents told the LPA that on average, facility staff attend to them within five (5) to fifteen (15) minutes. Records review of the signal system alerts demonstrated that on average, more than eighty (80) percent of calls were responded to in under 15 minutes with an additional ten (10) percent of calls coming in under 20 minutes. This corroborates resident interviews. On 04/16/2026 it was alleged "Staff did not ensure resident's room was clean." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "Staff did not ensure resident's room was clean", it was alleged facility staff do not clean resident rooms on a regular basis. Resident interviews revealed that facility staff clean rooms once a week. All interviewed residents stated that they had no issues with getting help from staff to clean rooms. Interviewed resident rooms were clean and sanitary. Records review revealed that facility staff have assigned rooms to a schedule of cleaning and sign off on the shift that the room was cleaned. Residents whose rooms are not cleaned on their assigned days are given the opportunity for staff to come at a later time to perform cleaning duties. LPA Observations of rooms in the facility demonstrated that rooms in both the memory care and assisted living portions of the facility were clean and sanitary. This corroborates resident interviews. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with ED Brandon Cho, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jul 9, 2026 · control 08-AS-20260409121610

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Executive Director (ED) Natalie Carlborg. The facility serves 214 residents ages 60 and above, of which 23 are ambulatory and the remaining residents may be non-ambulatory, including 25 bedridden. Delayed egress was approved in building C1. Hospice waiver was approved for 25 residents. During today’s inspection, there were a total of 102 residents in care. This facility does feature a secured perimeter. LPA and ED 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, screens, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. A pool was present at the facility. The pool fence was at least 5 feet high and the fence did not obstruct the pool from view. The gates to enter the pool were self-latching. Per ED, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and delayed egress doors were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) and Personal Protective Equipment were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with ED to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 19, 2026

Allegation investigated: Staff left resident in a soiled diaper for an extended period of time Staff did not respond to residents call button in a timely manner Staff did not administer residents medication in a timely manner Staff did not safeguard residents personal belongings Staff are not providing adequate food service to residents Staff did not ensure residents plugs in room are not in disrepair Unlawful eviction

On 02/23/26 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint investigation, explained the purpose of the Zoom meeting and delivered investigation findings to ED. On 10/18/22, 12/01/22 and 03/01/23, LPA L Silveira conducted interviews with reporting party (RP), residents (R2, R3) and staff (ED, H1, H2) and made observations in random residents’ apartments (R1, R2, R3, R4, R5). Review of RCFE Laguna Estates Senior Living facility # 374604065 history showed a change of ownership effective 04/15/2019 to Vista Carlsbad Village Senior Living with no change in facility number. During investigation, LPA L Silveira obtained the following documents from ED: Personnel record, Residents’ roster, admission agreements, call button records, charting notes, R1 timeline of issues, eviction notice, medication records, pest control reports, resident face sheets, SOC341 and photos. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Staff left resident in a soiled diaper for an extended period of time Finding: Unsubstantiated During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). Review of R1’s timeline of issues at the facility showed R1 engaged in inappropriate behaviors towards staff and disturbed other residents from 05/08/22 to 10/23/22. This included R1’s refusal to allow staff to change his soiled brief on the following dates – on 08/02/22 R1 refused to allow staff to change his brief stating he wanted police to change him (R1 called 911); 08/21/22 R1 refused to allow his soiled brief to be removed by staff and preferring it to be left on the floor so police could see it (R1 called 911); 09/18/22 R1 refused to allow care team to change his soiled brief and blew a whistle when he was brought to the lobby disturbing other residents. On 10/09/22 and 10/12/22, R1 refused to allow staff to change his soiled brief and clothing, was verbally abusive to staff, attempted to kick staff and called 911 stating his care needs are not being met. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation staff left resident in a soiled diaper for an extended period of time was found to be unsubstantiated. Allegation: Staff did not respond to residents call button in a timely manner Finding: Unsubstantiated During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). ED stated R1 has dementia who kept his call pendant light on 24/7. Staff (PD) witnessed R1 hit/scratch care staff, used foul language towards caregivers on 07/21/22, wouldn’t allow them to reset his call pendant, swung a broom at staff on 08/23/22 and would constantly call 911 stating staff was intentionally trying to harm, poison and kill him. On 09/17/22 R1 refused care team and would not allow them to reset his call pendant. ED stated R1 would constantly call 911 stating care staff was not attending to his needs. On 09/18/22 R1 refused to allow staff to change his brief and was brought to the lobby with whistle and created disturbance. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation staff did not respond to residents call button in a timely manner was found to be unsubstantiated. Continued on next page, LIC 9099C pg1 Allegation: Staff did not administer resident’s medication in a timely manner Finding: Unsubstantiated During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). Review of R1’s timeline of issues showed R1 engaged in inappropriate behaviors towards staff and disturbed other residents from 05/08/22 to 10/23/22. This included R1’s refusal to take his insulin medication on 07/15/22, 07/27/22 and 10/15/22 as well as constantly arguing with staff regarding his insulin dosages. On 09/24/22, R1 exited his apartment and struck care staff, accusing staff of poisoning him. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not administer resident’s medication in a timely manner was found to be unsubstantiated. Allegation: Staff did not safeguard resident’s personal belongings Finding: Unsubstantiated During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). ED stated that R1 was first admitted at the facility in March 2022. ED stated R1 has dementia, paranoia and required a higher level of care. Review of R1’s documents did not show any theft or loss incident reports while R1 was in care at the facility. LPA also interviewed other residents (R2, R3) who stated that they did not have any missing items in their rooms. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not safeguard resident’s personal belongings was found to be unsubstantiated. Allegation: Staff are not providing adequate food service to residents Finding: Unsubstantiated During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). ED stated R1 was first admitted at the facility in March 2022 and engaged in inappropriate behaviors towards staff and other residents from 05/08/22 until his eviction on 11/30/22. ED stated RP stated R1 wouldn’t allow the call light to be turned off, wouldn’t allow care staff to change his briefs, would argue with staff regarding his dosages of insulin, would yell racist and derogatory statements to a Black nurse, calling him “nigger”, would call 911 often, claiming he wasn’t receiving care. On 03/01/23, LPA interviewed R2 and R3 who stated they had no issues with food services at the facility. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not providing adequate food service to residents was found to be unsubstantiated. Continued on next page, LIC 9099C pg2 Allegation: Staff did not ensure residents’ plugs in room are not in disrepair Finding: Unsubstantiated On 12/09/22, LPA L Silveira conducted a walk through with ED at the facility of the following random bedrooms – B211, B219, B213, B318). LPA did not observe any electrical cover missing in the outlets nor wires sticking out of them during the walk through. ED stated R1 or his authorized representative did not report any electrical outlet issues with management while R1 was still residing at the facility. LPA also interviewed residents (R2, R3) who stated that they did not observe any missing electrical outlet covers or exposed electrical outlet wirings inside their apartments. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure residents’ plugs are not in disrepair was found to be unsubstantiated. Allegation: Unlawful eviction Finding: Unsubstantiated During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). Review of R1’s timeline of issues showed R1 engaged in inappropriate behaviors towards staff and disturbed other residents from 05/08/22 to 10/23/22. ED notified R1 and RP on 06/26/22, that continued inappropriate behaviors towards staff, accusing them of intentionally harming R1 and calling 911 constantly were in violation of the facility’s rules regarding good conduct and that further incidences may result in the termination of R1’s admission agreement. On 10/13/22, R1 physically and verbally assaulted care staff in the lobby witnessed by other staff and management who called 911 and notified RP that R1 is no longer compatible at the community. On 11/01/22, ED stated they issued R1 and RP a 30-day eviction notice effective 11/30/22 for non-payment of basic services, violations of facility policies and incompatibility with other residents in care. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation of unlawful eviction was found to be unsubstantiated. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 23, 2026 · control 08-AS-20221201102413

Allegation investigated: Facility has pests Facility is not maintained clean and sanitary Resident was not provided housekeeping services

On 02/23/26 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint investigation, explained the purpose of the Zoom meeting and delivered investigation findings to ED. On 10/18/22, LPA L Silveira conducted interviews with reporting party (RP), residents (R2, R3) and staff (ED, Housekeeping H1, H2) and made observations in random residents’ apartments (R1, R2, R3, R4, R5). Review of RCFE Laguna Estates Senior Living facility # 374604065 history showed a change of ownership effective 04/15/2019 to Vista Carlsbad Village Senior Living with no change in facility number. During investigation, LPA L Silveira obtained the following documents from ED: Personnel record, Residents’ roster, admission agreements, call button records, charting notes, eviction notice, medication records, pest control reports, resident face sheets, SOC341 and photos. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Facility has pests Finding: Unsubstantiated During investigation, LPA L Silveira interviewed staff (ED & Housekeeping staff – H1, H2) and residents (R2, R3). On 10/18/22, LPA toured the facility with ED and randomly visited 5 residents’ rooms (Room B316, B317, B318, B321 & B315). LPA did not observe any signs of cockroaches or pest droppings in any of the bedrooms visited. LPA checked bathrooms, behind trash bins, closets, corners of all bedrooms and observed all rooms clean with no health or safety issues. LPA also interviewed residents (R2, R3) who stated that they did not observe any cockroaches, rats or ants in their apartments. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation that facility has pests was found to be unsubstantiated. Allegation: Facility is not maintained clean and sanitary Finding: Unsubstantiated During investigation, LPA L Silveira interviewed staff (ED & Housekeeping staff – H1, H2) and resident (R2, R3). On 10/18/22, LPA toured the facility with ED and randomly visited 5 residents’ rooms (Rooms B316, B317, B318, B321 & B315). ED stated that R1 who lived in Rm# B318 was unsanitary (refused to let staff change his soiled diapers) and would deliberately drop food all over the floor, disrespectful with staff and refused to let housekeepers enter, clean the room and take out the trash. LPA L Silveira observed room B318 looked like it had recently been cleaned, floor had minor carpet stains and bed linens were clean. All random rooms were observed clean with no health or safety issues. LPA also interviewed residents (R2, R3) who stated that staff cleaned their apartments regularly, changed beddings with fresh linen and emptied trash bins. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that is not maintained clean and sanitary was found to be unsubstantiated. Continued on next page, LIC 9099C pg1 Allegation: Resident was not provided housekeeping services Finding: Unsubstantiated During investigation, LPA L Silveira interviewed staff (ED & Housekeeping staff – H1, H2) and residents (R2, R3). ED stated that R1 who lived in Rm# B318 was unsanitary, would drop food all over the floor, disrespectful with staff and refused to let housekeepers enter, clean the room and take out the trash. On 10/18/22, LPA toured the facility with ED and randomly visited 5 residents’ rooms (Rooms B316, B317, B318, B321 & B315). LPA L Silveira observed room B318 looked like it had recently been cleaned. There were minor carpet stains. R1’s bed linens were observed clean. All other random rooms were also observed clean with no health or safety issues. LPA also interviewed residents 9R2, R3) who stated that housekeeping staff cleaned their rooms regularly and took out their trash. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that resident was not provided housekeeping services was found to be unsubstantiated. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 23, 2026 · control 08-AS-20221013142405

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced Case Management visit. LPA was met by Natalie Carlborg, Executive Director (ED), and was granted entry into the facility. At the time of the visit, there were 91 residents currently in care. This visit was initiated due to a self-reported incident involving Resident 1 (R1), which was received by Community Care Licensing (CCL) on August 11, 2025 (08/11/25). The incident involved R1 eloping from the facility unassisted and sustaining a fall that resulted in hospitalization. R1 was later diagnosed with multiple facial fractures and transferred to a trauma center for further evaluation. During the investigation, interviews were conducted with facility staff and outside sources. Interviews revealed that R1 had a documented history of dementia and Parkinson’s disease and required assistance with medications and eye drops. Staff acknowledged that R1 had cognitive impairments but in interviews consistently described R1 as “independent.” Several staff members confirmed that on the day of the incident, R1 was last seen walking out the front door unassisted and that staff did not intervene due to their “independent” status. Interviews with Outside Source 1 (OS1) about R1 reported that R1’s cognitive condition had declined significantly in recent months, including increased confusion and reduced verbal communication. This decline was reported to facility staff and UCSD Neurology - Memory Care Program and should have triggered a reappraisal of R1's condition and care needs. Record review indicated that R1’s cognitive function had been gradually declining, and that R1 had been having increasing difficulties with confusion, recognizing their own handwriting, and decreasing levels of alertness as of their last visit on 7/24/2025. Additionally, multiple members of staff confirmed that R1 had recently experienced the loss of their pet dog, which had previously provided companionship and routine structure. The loss of the pet represents a significant mental or social trauma as defined in CCR Title 22, Section 87463(b)(1)(D), and should have triggered a reappraisal of R1’s condition and care needs. Despite these indicators of cognitive decline and social trauma, there was no evidence that the facility updated R1’s appraisal or conducted a reappraisal as required by regulation. One (1) deficiency was cited per California Code of Regulations, Title 22. (refer to the LIC809-D page). Plans of Correction were jointly developed with the Exectuvei Director. An exit interview was conducted with Natalie Carlborg, Executive Director to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Dec 16, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(b)(1)(D) · Plan of correction due date: Dec 30, 2025

87463 Reappraisals (b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition... (1) Significant changes in condition, as defined in Section 87101, Definitions, include, (D) A mental or social trauma, such as the loss of a loved one. Based on observation, interview, and record review, the licensee did not ensure that resident received a reappraisal after significant change in condition, which posed a potential Health, Safety, and Personal rights risks to 1 of 91 persons in care.the state’s words, verbatim · CDSS document, Dec 16, 2025

Plan of correction: Licensee stated they will continue to provide Elopement Prevention and Reappraisal Training initiated by this event. The training began 08/24/2025. Proof of this plan of correction will be submitted to CCLD Offices no later than 01/16/2026

Allegation investigated: Staff did not assist resident with toileting needs. Licensee does not ensure sufficient number of staff on site to redirect residents from exiting the memory care unit.

On 11/5/2025 at 1pm, Licensing Program Analyst (LPA) Luisa Fontanilla met with Kimberly Bonn via Teams to deliver finding for the above allegations. LPA explained to Bonn the purpose of the meeting. On June 21, 2024, LPA Liliana Silveira attempted to contact Reporting Party (RP) via email to conduct pre investigation, 10-day visit, interviewed staff and obtained records. On August 6, 2024, RP contacted LPA Silveira via email and sent a message saying, “Thank You for getting back to me…. Please DISREGARD all my emails at this time regarding Laguna Estates Senior Living.” The email also indicated a request from RP not to be contacted by LPA. During the June 21, 2024 visit, LPA Silveira interviewed Resident Services Coordinator (RSC) and Executive Director (ED) Kimberly Bonn. LPA also conducted an inspection of 3 resident rooms including R1’s. continuation on Lic 9099C Unsubstantiated con't from Lic 9099 Staff did not assist resident with toileting needs. Based on LPA Silveira’s observations, bedding, linens, walls and bathrooms were clean. LPA did not observe any stains or fecal matter anywhere in the bedrooms. The bed linens were all clean. On June 21, 2024, ED states, “Two months ago…. R1 is independent and even though R1 needs toileting assistance, R1 will try to go to the bathroom and do things without staff assistance. Staff have found soiled briefs on the floor and in R1’s walker.” A review of R1’s Individual Service Plan (ISP) indicates R1 needs total assist with toileting. Licensee does not ensure sufficient number of staff on site to redirect residents from exiting the memory care unit. On June 21, 2024, LPA Silveira interviewed ED who states that R1 attempted to exit the facility twice: January 28, 2024, and May 26, 2024. And on those occasions, staff were able to redirect R1 and prevented R1 from exiting the facility. RSC states that R1’s exit seeking behavior is being addressed by keeping R1 engaged in activities to help decrease elopement tendencies. At the time of interview, R1 was “put to assist med techs to deliver medications.” Based on records review and interviews conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. No deficiency is noted. A copy of this report was provided to Bonn.the state’s words, verbatim · CDSS document, Nov 5, 2025 · control 08-AS-20240619114311

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director (ED), Kim Bonn. Today's visit was in response to an LIC624 Incident Report regarding absent without official leave (AWOL) of a resident (R1) . The licensee self reported the incident to Community Care Licensing (CCL) on 8/11/2025. [See LIC 811 Confidential Names List identifying R1.] During today’s visit, LPA performed a facility tour/welfare check, collected records, and spoke briefly to ED, Kim Bonn. There were no deficiencies cited during today's visit. However, this incident may require further follow-up visits and may warrant a deficiency. An exit interview was conducted with ED Bonn, to whom a copy of this report, confidential list (LIC811), and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Aug 11, 2025

Allegation investigated: Licensee is not adequately addressing a communicable disease outbreak at the facility. Staff are not seeking medical attention for residents as necessary.

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced visit to the facility to deliver investigative findings regarding the above mentioned allegation. LPA identified herself, explained the purpose of the visit and nature of the complaint to Executive Director Kim Bonn. On April 2, 2025 the Department received this complaint which alleged licensee is not adequately addressing a communicable disease outbreak at the facility and staff are not seeking medical attention for residents as necessary. The Department’s investigation included a facility tour, record reviews, as well as interviews with residents, staff and outside sources. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) It was specifically alleged that licensee did not adequately address scabies amongst residents. Resident records reviewed did not indicate any diagnosis of scabies to warrant infection control plans being initiated. While there was one former staff caregiver interviewed who suspected residents were displaying symptoms of scabies, interviews with current staff nurses and caregivers unanimously reported not having concerns of residents exhibiting symptoms of scabies. Interviews with current staff also reported interacting directly with residents and noted that due to scabies highly contagious nature, staff would likely be infected if it were present amongst residents and went unaddressed. Further, records reviewed and interviews corroborated some residents needing skin treatment care for symptoms of itchiness, but not for any communicable condition. Regarding the allegation that staff are not seeking medical attention for residents as necessary, records reviewed demonstrated facility communicating with outside providers and following treatment care plans. Further, interviews with resident's responsible parties did not report concerns regarding lack of medical attention for residents. The Department has investigated the above allegations. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated. An exit interview was conducted with Executive Director Kim Bonn, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Jul 22, 2025 · control 08-AS-20250402144855

Allegation investigated: Staff did not ensure that facility was free from pests

On 05/29/25, Licensing Program Analyst (LPA) L. Holmes from the Oakland Regional Office delivered the finding for the above allegation that was investigated by Licensing Program Analyst (LPA1), Kristina Ryan. LPA1 conducted an unannounced need further investigation on 03/24/2021. LPA1 virtually toured the facility and discussed the purpose of the visit with Donelle William Administrator (ADM), and James Ringhoff Executive Director (ED) During the investigation, LPA1 conducted Staff and Resident interviews, and obtained additional documents. Allegation: Unsubstantiated Staff did not ensure that facility was free from pests Continued on LIC9099... Unsubstantiated ...continued from LIC9099. ADM states that he/she has never seen roaches in any other parts of the facility, but there have been sightings in the B and C buildings. LPA1 observed traps were empty, resident’s room was clean, and Orkin puts down Bait Traps to determine what kind of pests are present in the space. Based on information obtained, the allegation is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that the allegation is not valid because the preponderance of the evidence standard has not been met. No signatures were obtained by the Oakland Regional Office, and a certified copy will be mailed to the Licensee.the state’s words, verbatim · CDSS document, May 29, 2025 · control 08-AS-20210315081809

Allegation investigated: Licensee did not allow resident to keep their bed rails on their bed.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to commence a Complaint Investigation regarding the above allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Receptionist Lyn Anzalone. LPA then met and debriefed with Executive Director Kimberly "Kim" Bonn and Health Services Director Katie Ferguson. The Complainant alleged that Licensee did not allow Resident #1 (R1) to keep their bed rails on their bed. [See LIC811 Confidential Names List for a description of R1.] CCLD’s investigation involved an unannounced facility tour/welfare check and interviews of R1, pertinent staff, and pertinent outside sources. The Department also reviewed relevant care and administrative records. [CONTINUED ON LIC 9099-C, 1 of 2] Substantiated [CONTINUED FROM LIC 9099] Per R1’s Face Sheet, they had lived at the facility since February 2024. Per R1’s LIC602 Physician’s Report, corroborated by their Preplacement Appraisal and latest Individual Service Plan: R1’s primary diagnosis and reason for being at the facility was hemiplegia and hemiparesis following a stroke. R1 experienced residual left sided weakness and had history of knee replacement. R1 required hands-on staff assistance with transferring in/out of bed, and with rotating/repositioning in bed, among other activities of daily living. During his 05/19/2025 visit, LPA observed: R1 had a hospital bed in their bedroom, but the pair of half-length bed rails were not affixed to R1’s bed. The rails were instead set aside on the floor. Staff interviews showed: R1 rented their hospital bed (which came with the rails) from a third-party durable medical equipment (DME) company. (Therefore, both the bed and the rails in question were R1’s personal property, and not Licensee’s property.) About one month earlier, facility manager Staff #1 removed R1’s bed rails from R1’s bed, because the rails conflicted with Licensee’s internal facility/company policy. LPA subsequently obtained a copy of Licensee’s internal facility/company policy, which stated in part: “The use of bed rails is discouraged [at the facility]. Half bed rails are only utilized to assist in mobility and not as a restraint and are only used with specific physician’s order mandating the use and will require the permission of the Regional Director of Health Services.” California Code of Regulations, Title 22, Section 87608 titled “Postural Supports,” states in part: “(a)(5)(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.” Regulation does not require a physician’s order for half-length bed rails. CCLD also reviewed the Admissions Agreement contract between R1 and Licensee, finding no mention of the facility’s stance/policy on bed rails. [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] Interviews further showed: For most of R1’s residency at the facility (over a year), R1 had bed rails on their hospital bed, without issue. R1 and their responsible person (RP) both affirmed to CCLD their strong preference for R1 to have the half-rails affixed to their bed, because they help R1 feel more secure and are a potential grab-point for R1’s hand during assisted transfer/rotation maneuvers. Neither person considered the half-rails to be a restraint. Both persons were unaware of Licensee’s reasoning for removal of the bed rails. R1 subsequently communicated their desire for their rails to be reattached to facility direct care staff (as confirmed by both R1 and direct care staff). Licensee therefore had constructive knowledge to timely remedy. Based on records and interviews, a preponderance of evidence exists to show Licensee did not allow Resident #1 (R1) to keep their bed rails on their own bed. The allegation is therefore Substantiated, and one (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Executive Director Kim Bonn and Health Services Director Katie Ferguson, to whom a copy of this report, the LIC 9099-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 19, 2025 · control 08-AS-20250514140214

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(14) · Plan of correction due date: May 30, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (14) To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility…” This requirement was not met, as evidenced by: Based on records review and interviews, Licensee did not reasonably accommodate the individual need/preference of 1 of 93 residents (R1) regarding their life at the facility, when the specific accommodation that R1 requested was reasonable with respect to safety. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 19, 2025

Plan of correction: Licensee agreed arrange for R1’s half-length bed rails to be reattached to their hospital bed as soon as possible, and to E-mail photos of such to LPA, by the POC due date. Doing so will satisfy regulation, as it is written. [This does not preclude Licensee from subsequently coordinating with R1’s physician and/or responsible person (RP) to do any of the following, if it pleases Licensee: a) pursing a doctor’s order for R1’s half-rails; b) conferring with Licensee’s Regional Director of Health Services; and/or, c) inquiring with R1 and RP to see if they would prefer a Halo Rail over a half-length bed rail.]

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angelica Boyles 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 Kim Bonn. According to the facility’s license, the facility serves 214 residents ages 60 and above, of which 23 are ambulatory and the remaining residents may be non-ambulatory, including 25 bedridden. Delayed egress was approved in building C1. Hospice waiver was approved for 25 residents. During today’s inspection, there were a total of 95 residents in care. This facility does feature a secured perimeter. LPA, accompanied by Executive Director, toured the interior and exterior of the facility, and inspected a sample of bedrooms. 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. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility had a comfortable ambient internal temperature. Hot water temperature at taps accessible to residents were all compliant. 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, fireplaces, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. (continued on next page, LIC 809-C) A pool was present at the facility. The pool fence was at least 5 feet high and the fence did not obstruct the pool from view. The gates to enter the pool were self-latching. Per Executive Director, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and residents. LPA reviewed multiple staff and residents records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Executive Director also presented proof of current/active business liability insurance. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Executive Director, Kim Bonn to whom a copy of this report was provided during the visit.the state’s words, verbatim · CDSS document, Apr 1, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Interim Executive Director Divinia Nunez. According to the facility’s license, the facility serves 214 residents ages 60 and above, of which 23 are ambulatory and the remaining residents may be non-ambulatory, including 25 bedridden. Delayed egress was approved in building C1. Hospice waiver was approved for 25 residents. During today’s inspection, there were a total of 108 residents in care. This facility does feature a secured perimeter. LPA, accompanied by Divinia, toured the interior and exterior of the facility, and inspected a sample of bedrooms. 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. The facility’s ambient internal temperature was 72 F. Hot water temperature at taps accessible to residents were all compliant: Bedroom B105 bathroom sink was 111.9 F, Bedroom B102 bathroom sink was 110.4 F, bedroom A111 bathroom sink was 114.1 F and bedroom C106A bathroom sink was 112.2 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, fireplaces, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. (continued on next page, LIC 809-C) A pool was present at the facility. The pool fence was at least 5 feet high and the fence did not obstruct the pool from view. The gates to enter the pool were self-latching. Per Divinia Nunez, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed multiple staff and residents. LPA reviewed multiple staff and residents records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Divinia also presented proof of current/active business liability insurance. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Divinia, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit. ***NOTE: LPA left the facility for one hour during the visit.the state’s words, verbatim · CDSS document, Apr 25, 2024

Allegation investigated: Staff did not communicate with resident's authorized representative of resident's change of health conditions. Resident's hygiene needs were not met. Staff did not safeguard resident's property. Staff are mismanaging resident's medication

Licensing Program Analyst (LPA) Ramon Serrano, conducted an unannounced Complaint Visit. LPA introduced himself and discussed the purpose of the visit with Regional Director of Operations Divinia Nunez. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review and interviews with facility staff, residents and outside sources. It was alleged that facilty staff did not communicate with authorized representative of Resident 1 (R1) change of health conditions(an LIC 811 Confidential Names List was provided to the facility representative to identify the resident) Review of facility policy revealed that any changes in resident's condition witnessed by facility staff would be reported to the Licensed Nurse. The Licensed Nurse would evaluate the resident and would be responsible for notifying the resident's responsible party and physician if appropriate. Interview with Health Services Director (HSD) revealed at the moment a change of condition was known HSD would call the family right away. Unsubstantiated HSD stated that she has no doubt that facility staff would have called R1's responsible party to advise of maintained that they adhered to the facility's protocols for communicating health changes with authorized representatives. It was alleged that R1's hygiene needs were not met. Review of Facility policy revealed that residents would be scheduled to bathe a minimum of twice per week. If a resident resisted or refused the scheduled bath, repeated attempts would be made at intervals throughout the day and evening, by different staff members. Following each time a resident used the toilet, the perineal and buttocks area will be cleaned as necessary, utilizing appropriate personal cleaning products. It should be noted that above allegation was made during the Covid-19 pandemic which could have caused occasional delays in response to hygiene requests, but there was no evidence to support a systemic failure in meeting the resident's hygiene needs. It was alleged that facility staff did not safeguard R1's property. Documentation was reviewed regarding the facility theft and loss program. Interview with Resident 2 revealed R2 has never had any items stolen. R2 stated R2 had not experienced staff not safeguarding resident property. No instances of negligence or mishandling of R1's property were identified during the investigation period. It was alleged that staff mismanaged R1's medication. Review of medication management policy revealed the facility would make a reasonable effort to maintain a current list of all medications, including over the counter medications, being self administered by each resident, to be used in case of an emergency. Whenever a resident has a change in medication regime the resident should notify the facility so the staff may update their medication list. LPA interviewed Staff 1 (S1) who stated that whenever a resident moves out of the facility a "medication reconciliation" is conducted with the resident and/or responsible party depending on the residents capabilities. The medication is "counted back" to the responsible party. The responsible party acknowledges that they received the medication back and the quantities of medication. Records review revealed the following; R1 was ambulatory, R1 was able to bathe self, R1 was able to administer own prescription medications and R1's physical health status was "good." R1 completed a mental status examination on April 17, 2019. R1 scored a 29 out of 30. R1 wrote on the last page of the exam; " I just took a test and found it very easy." Outside source (OS) statement dated April 4, 2019 indicated that OS was in support of R1 residing in "independent living" level of care. OS stated that R1 had been under their care since January 28, 2015 and OS had weekly contact with R1 regarding R1's mental health issues. OS stated that R1 was psychologically appropriate for independent living. LPA interviewed Outside Agency (OA). OA stated that OA had no knowledge of any of the complaint allegations. OA further stated that OA has not witnessed any of the listed allegations. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. An exit interview was conducted with Divinia Nunez. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Divinia Nunez whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Apr 23, 2024 · control 08-AS-20201230093215

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Jonathan Thomas and Resident Care Coordinator Mirayda Fleming. Today's visit was in response to an LIC624A Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 03/20/24). [See LIC 811 Confidential Names List for a description of R1.] During today’s visit, LPA performed a facility tour/welfare check, collected records, and spoke briefly to Jonathan. There were no deficiencies cited during today's visit. An exit interview was conducted with Jonathan, 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, Mar 22, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Jonathan Thomas. Today's visit was in response to an LIC624 Unusual Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 03/13/24). The facility self-reported a medication management issue with Resident #1(R1) [See LIC 811 Confidential Names List for a description of R1.] During today’s visit, LPA requested records, and spoke briefly to Jonathan about the incident. There were no deficiencies cited during today's visit. An exit interview was conducted with Jonathan, 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, Mar 22, 2024

Allegation investigated: Licensee did not safeguard resident belongings

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above mentioned allegation. LPA was greeted by, identified herself to, and explained the purpose of the visit with Resident Care Coordinator (RCC) Mirayda Fleming. During today's visit, LPA observed residents in care and interviewed staff. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the licensee did not safeguard resident belongings. Interviews revealed that Resident 1 (R1) claimed that multiple clothing items had gone missing from their room and that R1 had notified facility management of the missing items. Continued on LIC9099-C page... Unsubstantiated Review of the facility’s admission agreement revealed that residents and their representatives were informed that the facility would not be liable for any items going missing unless those items were provided to the facility for safekeeping or in the event of staff theft. Review of R1’s personal inventory document revealed that R1 and their responsible party did not entrust any items to the facility’s care. Interviews with residents and outside sources revealed that some items such as clothing or costume jewelry would occasionally go missing, but those interviews did not reveal any indication of staff stealing, taking, or misplacing resident belongings. Interviews with facility management did not reveal that management was aware of R1’s allegations of personal belongings going missing. Review of theft reports submitted to the Department did not reveal a report for R1’s claims, and pursuant to management’s statements, R1 did not disclose the missing items to facility management. Interviews with staff revealed that residents would report their concerns regarding items going missing or being stolen to direct care staff, housekeeping, or facility management. Staff stated that in a majority of cases, items that residents reported missing were either visible in the resident’s room or were located after a search of the resident’s room and their purse or bag. Interviews revealed that in the previously mentioned cases, the residents often had memory impairments. Staff stated that after a report, staff would ask to search the resident’s room and request the resident to search their purse or bag. Interviews with staff revealed that staff were instructed to report any missing or stolen items to their supervisor. Facility management were responsible for reaching out to the resident’s family or responsible party and the Executive Director would file any reports of missing or stolen items, would contact 911 to make a report to law enforcement, and would notify the Department. Interviews revealed that if an item could not be located after a search of the resident's room or the facility, residents were encouraged to contact law enforcement to report the missing items or management would contact law enforcement on the resident’s behalf. Interviews with staff did not reveal any indication of staff stealing, taking, or misplacing resident belongings. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with RCC Mirayda Fleming, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).the state’s words, verbatim · CDSS document, Nov 7, 2023 · control 08-AS-20230918154637