Lakeshore Residential Care

Allegation investigated: Resident fell and sustained broken ribs from staff neglect Facility did not address bed bug issues. Facility mismanaged resident's medications.

On 4/23/2026 at 1:45pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to continue the complaint investigation and deliver complaint findings for the allegations above. LPA met with Gaffar Syed, Administrator and explained the reason for the visit. During the course of the investigation the Department conducted interviews with staff (S1, S2, S3, and S4), witnesses, obtained and reviewed records. Allegation: Resident fell and sustained broken ribs from staff neglect During initial interview W1 reported fall was possibly caused by another resident and/or care neglect from the facility. S1 stated he was not at the Continued on LIC9099C. Unsubstantiated Continued from LIC9099. facility at the time of the incident, however, he received a call from S3. S3 stated during interview that she did not witness the fall, but was called to come assist when it occurred. S3 observed R1 down on the floor near the piano. S4 stated she witnessed R1 fall and hit either her back or side on the corner of the table. Both (S3 and S4), stated R1 was placed in a chair, R1 stated she was in pain, and 9-1-1 was called. S2 stated during interview that R1 had not fallen before. R1 could not be interviewed due to the diagnosis. LPA reviewed R1's physician report dated 5/29/2025, which indicated R1 did not have any motor impairment and was ambulatory. Allegation: Facility did not address bed bug issues. During interview it was reported by W2 that R1's room had bed bugs in 2024 and R1 was moved to another room. W1 stated during interview that the facility took care of "that issue" and the allegation should not be addressed. S2 stated there is no bed bugs at the facility. LPA reviewed complaints and case management visits back to 2023 and did not observe any case of bed bugs. As of today's date the facility do not have a bed bug issue. Allegation: Facility mismanaged resident's medications. During interview W2 reported when R1 first moved to the facility she was active until the additional medication was given. W1 stated the medication was documented each time R1 was given medication and doesn't feel it was mismanaged. LPA reviewed the medication administration record (MAR) for January and February 2026, and observed each day R1 was at the facility it Continued on LIC9099C. Continued from LIC9099C. was documented the medication was given as directed. S2 stated she administers the medication. S2 recalled sometimes R1 would refuse medication, S2 would wait for a little while and go back, and R1 would take the medication. Based upon the information obtained and the interviews conducted during the investigation, the above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 15-AS-20260223165309

Type of visit: Case Management - Deficiencies

On 04/15/2026 at 4:17PM, Licensing Program Analyst (LPA) Carol Fowler was at the facility for a complaint investigation (#15-AS-20260406090956), the following deficiencies were observed. During the complaint investigation, LPA observed the following: *Medication room unlocked which contained medication such as Benadryl. *Pre-poured medication. *Unlocked chemical. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of this report, and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(5) · Plan of correction due date: Apr 16, 2026

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having pre-poured medication which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Administrator will submit a written statement of having read and understood the regulation and conducted in-service training with all staff, providing CCLD with a copy of all signatures of staff attended no later than the POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a)(b) · Plan of correction due date: Apr 16, 2026

a) Except as specified in subsection (b)the licensee ... that disinfectants, cleaning solutions, poisonous... objects, and other similar items which ...r to residents are in locked storage and are not left unattended... locked storage. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having unlocked cleaning solution which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Staff locked up the items during inspection. Deficiency cleared.

Type of visit: Case Management - Health Checks

On 3/3/2026, at 11:35am, Licensing Program Analyst (LPA), L. Hall arrived unannounced conduct a case management health and safety check. LPA met with Gaffar Syed, Administrator, and explained the reason for the visit. During the health and safety check, LPA toured the facility including but not limited to common areas, kitchen, bathrooms, bedrooms and outdoor common area. LPA observed servers passing dinner to residents. Resident were in the common area, hallways, and bedrooms. The facility is noted to be clean, in good repair, and residents in care appear to be safe. There is a minimum of 7-day non-perishables and 2-day perishables foods. There are no imminent health concerns on today's date. LPA observed the following deficiency during visit: At 3:25pm, LPA observed front entry door was locked from inside. A key had to be used to open door. Continued on LIC809C. Continued from LIC809. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights and this report provided.the state’s words, verbatim · CDSS document, Mar 3, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Mar 10, 2026

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: 6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having from entry door unlocked from the inside, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 3, 2026

Plan of correction: Administrator immediately unlocked front entry door and left it unlocked. Deficiency cleared during visit.

Type of visit: Required - 1 Year

On 12/23/2025 at 9:05 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Gaffar Syed, and explained the purpose of the visit. LPA toured the facility inside and out including but not limited to residents' rooms, bathrooms, activity room, kitchen, and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms is adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents shared bathroom were measured at 108.3 and 107.8 degrees Fahrenheit. Residents’ shower bathroom are equipped with grab bars and non-skid shower pans. Carbon monoxide detectors were in operating condition during visit. Fire alarm was last inspected on 10/24/2025. Hallway fire extinguisher and kitchen fire extinguisher were last serviced on 10/22/2025. Emergency Disaster Plan was last posted on 11/25/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 09/28/2025. At 10:00 AM, LPA reviewed 5 residents records. At 11:16 AM, LPA reviewed 5 staff records and 3 of 5 have current first aid training and 4 of 5 are associated with the facility. LPA reviewed a sample of resident’s medications. Continue to LIC809-C... Continue from LIC809... Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 12/30/2025: LIC 308 Designation of Administrative Responsibility LIC 500 Personnel Report Infection Control Plan THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 11:53 AM, record review revealed that the liability insurance does not cover enough per occurrence and total annual aggregate. At 12:05 PM, LPA observed the S2 is not associated with the facility. At 12:23 PM, LPA observed that the Administrator was unable to provide staff training conducted in 2025. At 12:34 PM, LPA observed the shower room for the residents’ used as a storage room filled with debris. At 12:45 PM, record review and interview with S2 revealed that R2 and R5 do not have an updated appraisal needs and services plan. The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 23, 2025

The state marks this report as 10 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Staff are mishandling a resident's medication

On 9/05/25 at 1:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver filings in regard to the above allegation. LPA met with Gaffar Syed, Administrator, and explained the purpose of the visit. During the course of the investigation LPA interviewed W1, S1 and R1, reviewed R1’s file and medications. LPA corresponded with W1 via email. W1 would only say that a participant at the program where she works complained that the facility where he lives was miss-managing his medication. W1 would not provide LPA with the name of the participant. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** LPA interviewed S1 at the facility. S1 identified the individual in question as R1 and was well aware of R1's complaint. R1 does attend the program where W1 works and often complains about not getting enough medication. S1 stated that R1 is on a controlled medication so the facility must take extra steps to safeguard it. LPA reviewed medication administration records and compared them with the bubble packed medication. LPA found no discrepancies. LPA interviewed R1 via phone as he was at his program. R1 said he liked living at the facility. LPA asked about his medication and R1 replied “they don’t give me enough.” This agency has investigated the above complaint. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 5, 2025 · control 15-AS-20250828142143

Type of visit: Case Management - Other

On 7/10/25 at 3:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver amended report for complaint #15-AS-20250528164448. LPA spoke with Administrator Gaffar Syed who gave permission for care staff to sign the report. Amended report delivered to staff. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 10, 2025

Allegation investigated: Staff did not prevent resident on resident assault

This is an amended report. On 06/05/2025 at 2:10 PM, Licensing Program Analysts (LPAs) Greg Clark and Ardalan Gharachorloo arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Gaffar Syed, Administrator and explained the purpose of the visit. During the course of the investigation, LPAs interviewed S1, R1 and R2. LPA's also reviewed R1 and R2's facility files and the incident report dated 5/26/25. LPA Interviewed R1 who stated that she was struck by R2 on 05/23/2025 at around 1 pm, while sitting around the patio area of the facility. R1 also stated that she did not know why R2 struck her and that she was just sitting on the patio talking on her cellphone. ***CONTINUE ON 9099C*** Unsubstantiated ***CONTINUE FROM 9099** LPAs interviewed R2 who stated that did not hit R1 and that he never hits anyone stating "I don't want to get in trouble." R2 stated that he approached R1 and asked her to quiet down or leave the patio as he was " trying to meditate". LPAs interviewed S1 who stated that on 5/23/25 R1 was observed sitting in the patio area talking very loudly on her cellphone when another resident (R2) and asked R1 to quiet down. R1 then yelled out that R2 had hit her and then R1 called Oakland Police Department (OPD). S1 did not see R2 hit R1. S1 further stated that OPD arrived, interviewed both parties and issued citations to each of them. S1 also stated that R1 called 911 and went to the hospital to be checked out. LPAs reviewed the discharge papers from the hospital visit that documented there was no injuries to R1's face. During the course of the visit LPAs observed the facility residents to be quiet and respectful to each other space. S1 stated the facility is very mindful of not accepting residents who have a history of aggressive behavior as many of the residents in the facility are very vulnerable. On 7/10/25 LPA asked R1 about another incident that allegedly happened on 4/27/25 when R1 was allegedly attacked by R3. R1 could not recall the incident and didn't want to about it anymore. S1 said he did not recall any incident between R1 and R3 and that R3's room is on the opposite side of the facility from R1's room and it's not likely that the two had any interaction. This agency has investigated the complaint alleging staff did not prevent resident on resident assault. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 15-AS-20250528164448

Allegation investigated: -Staff did not seek medical attention for resident (R1) in a timely manner. -Facility has pests.

On this day, April 30, 2025, at 1:15 pm, Licensing Program Analyst (LPA) Delmundo conducted an unannounced visit to deliver the findings for the above allegations. LPA met with Gaffar Syed, administrator (ADM), and informed the reason for visit. During the course of investigation, the Department obtained copies of staff schedule, resident roster and the following residents' documents: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; Unusual Incident Report (UIR); hospital After Visit Summary. LPA interviewed the following: residents (R1, R2, R3) on 2/16/22; staff (S1, S2 and S3) on 2/16/22 and 4/30/25; witness (W1) on 4/29/25; R4 on 4/30/25; ADM on 4/30/25. LPA conducted inspection on 2/16/22. .....continued 9099C Substantiated Allegation: Staff did not seek medical attention for resident (R1) in a timely manner. The reporting party stated that R1 sustained laceration to the forehead, and it was still bleeding when Emergency Medical Team (EMT) arrived. RP further stated that R1 had fallen at 8:30am and the facility was delayed in seeking medical attention when R1 had bleeding. W1 stated that W1 came to the facility in the afternoon to attend to R1 who was bleeding when W1 arrived. W1 had to wrap R1’s head to control the bleeding. W1 further stated that the facility called the ambulance when it should be 9-11 that they should call, because R1 fell and was bleeding. LPA reviewed R1’s UIR which showed R1 fell at 8:15 am, was bleeding in the forehead and first aid performed. UIR also confirmed W1’s statement that ambulance was called at 3:00 pm. When LPA interviewed R1, R1 verbalized he was in pain. Based on interviews and records review, the allegation is substantiated. Allegation: Facility has pests. Two out of 3 staff and 2 out of 3 residents interviewed stated observing cockroaches. W1 also stated observing cockroaches in R1’s room. Therefore, the allegation is substantiated. Based on interviews which were conducted, the preponderance of evidence has been met, therefore the above allegations are substantiated. Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in civil penalty. Deficiencies and plan and proof of corrections were discussed with ADM. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided. Allegation: Resident (R1) had an incident while in care. Allegation: Resident (R1) sustained injury while in care. LPA interviewed R1 who was able to verbalized he was pain but unable to provide other information. R2, R3, R4 stated staff are okay. One of the staff interviewed stated not observing other staff being abusive or hurt any of the residents. Review of UIR showed R1 fell on 2/08/22 at the kitchen door in the hallway and sustained injury in the forehead. One of the 3 staff interviewed stated R1 fell near the kitchen. Review of R1’s LIC602A showed that although R1 has dementia but ambulatory. LIC625 did not indicate R1 needed assistance in ambulation. Based on interviews and record review and LPA unable to obtain information from R1 about the incident, the allegations are unsubstantiated. An unsubstantiated findings means that although the allegations may have happened or are valid, the preponderance of evidence standard has not been met. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Apr 30, 2025 · control 15-AS-20220209145931

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: May 1, 2025

87465 Incidental Medical and Dental Care: (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening........ -This requirement is not met as evidenced by: -Based on interviews and records review, the licensee did not comply with the section when R1 fell and sustained injury and staff did not call 9-1-1 immediately which posed an immediate health, safety and personal rights risks to person in care.the state’s words, verbatim · CDSS document, Apr 30, 2025

Plan of correction: Administrator to in-service the staff and submit copy of training topics with attendees signatures by 5/01/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 14, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. -This requirement is not met as evidenced by: -Based on interviews, the licensee did not comply with the section above in facility having cockroaches.the state’s words, verbatim · CDSS document, Apr 30, 2025

Plan of correction: Corrected. Administrator contracted with pest control company to eradicate the pest problems.

Allegation investigated: Staff yell at resident Staff do not follow residents care plan Staff do not allow resident to receive visitors Staff do not maintain facility is kept clean and free of odors Staff do not provide resident with housekeeping service Staff do not provide resident with toilet paper Staff do not provide residents with activities

On 12/17/24, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings in regard to the allegations above. LPA met with Gaffar Syed, Administrator and explained the purpose of the visit. During the course of the investigation LPA toured the facility, interviewed S1 and S2, four residents (R1, R2, R3 and R4). LPA also reviewed the care plans for R1, R2, R3 and R4, the facilities activity schedule and visitors’ policy. Allegation: staff yell at resident Three of the four residents interviewed (R2, R3 and R4) stated that the staff do not yell at them. All three stated that the staff were nice and that the staff were very helpful. R1 stated that S1 raises his voice when speaking to her. LPA has observed that S1 tends to speak in a louder than normal tone to the residents. S1 stated he does that because many of the resident are hard of hearing but denied raising his voice intentionally when speaking to R1. This allegation is unsubstantiated. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** Allegation: staff do not follow residents care plan LPA reviewed R1, R2, R3 and R4’s care plans. LPA also interviewed R1, R2, R3 and R4. LPA asked about the care they are receiving at the facility and all 4 residents confirmed that they are receiving the care that is outlined in their care plans. This allegation is unsubstantiated. Allegation: staff do not allow resident to receive visitors Interview with S1 and S2 revealed that R1 was allowing visitors to come back to her bedroom without the facility staff even knowing that the visitors were in the building. R1 was using her cell phone to contact her visitors. On one occasion one of the visitors, a male, was seen lying on R1’s bed. The facility’s visitation policy states that visitors must wait in the lobby for staff to get the residents they wish to visit and the visit should take place in one of the common areas of the facility. Since all of the rooms are shared this policy ensures that the right to privacy of the roommate is protected. LPA also reviewed the visitation policy in the facility’s admission agreement, and it states that visitors should “wait in the lobby for staff assistance when visiting residents.” This allegation is unsubstantiated. Allegation: staff do not maintain facility is kept clean and free of odors LPA has been at this location on numerous occasions over the past three years. LPA has always observed the housekeeping staff to be very attentive and preforming their tasks to ensure the facility is clean and free of orders. LPA has never observed the facility to be dirty or smelly. S1 stated that they have 3 full-time housekeepers on duty from 7:00 AM to 7:00 PM. It should be noted that many of the residents are incontinent and sometimes have incontinence in the common areas of the facility. It is the experience of the LPA that staff are quick to clean up the mess. This allegation is unsubstantiated. Allegation staff do not provide resident with housekeeping service As stated above the facility has three full time housekeepers. During numerous visits to the facility LPA has observed the housekeepers preforming their work, i.e. sweeping, and mopping the floors, dusting surfaces, emptying trash cans, cleaning the residents' rooms, etc. They rotate throughout the facility to ensure the facility is kept clean. Residents’ bathrooms are cleaned on a rotating schedule. This allegation is unsubstantiated. ***report continues on LIC9099C*** ***report continues from LIC9099C*** Allegation: staff do not provide resident with toilet paper LPA observed toilet paper in R1's bedroom and bathroom as well as in her locked closet. LPA also observed toilet paper in several of the other bathrooms at the facility. S1 and S2 also stated they tell staff to check for toilet paper when they are working with the residents. This allegation unsubstantiated. Allegation: staff do not provide residents with activities LPA reviewed the facilities activity schedule and observed that there were several activities each day for the residents to participate in. LPA also observed that the activities occurring match what is listed on the activity schedule. During LPA's interview with R1 she stated that she doesn't like to participate in the activities at the facility because she doesn't like interacting with the other residents. R1 prefers to stay in her room and read, exercise and journal. This allegation is unsubstantiated. This agency has investigated the allegations above. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 17, 2024 · control 15-AS-20240405144954

Allegation investigated: Staff do not safeguard resident's personal belongings

On 12/17/24, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings in regard to the allegation above. LPA met with Gaffar Syed, Administrator and explained the purpose of the visit. During the course of the investigation LPA interviewed the reporting party, S1 and R1 and toured R1's room. LPA interviewed R1 who stated that some of her belongings were being stolen by the other residents at the facility. Since many of the residents at the facility have dementia, it is more likely that they mistakenly took R1’s personal belongs thinking that the items belonged to them. S1 installed a lock on R1’s closet door to safeguard her personal belongings. LPA observed the lock on the closet door and that R1 had key to open it. ***report continues on LIC9099C*** Substantiated ***report continues from LIC9099*** LPA also reviewed R1’s needs and services plan that stated she is able to care for her personal belongings without staff assistance. Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted, a copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 17, 2024 · control 15-AS-20240405144954

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217 · Plan of correction due date: Dec 17, 2024

87217 Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents... personal property and valuables which have been entrusted to the licensee or facility staff. Based on observation the licensee did not comply with the section cited above. Items were being taked from a resident's room which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 17, 2024

Plan of correction: Administrator will install a lock on resident closet to protect her belongings

Type of visit: Required - 1 Year

On 12/17/24 at 1:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Gaffar Syed, Administrator and explained the purpose of the visit. LPA toured the facility including but not limited to bedrooms, bathrooms, activity room, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature in the kitchen was measured at 115.9 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 10/29/24 Emergency Disaster Plan was last posted on 12/13/24. First aid kit was observed to be complete. LPA reviewed 5 residents records and 5 staff records, and all were complete. LPA also reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 17, 2024

Allegation investigated: Staff do not administer resident's medications.

On 7/05/2024 at 11:00 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegation above. LPA met with Gaffar Syed, Administrator and explained the purpose of the visit. During the course of the investigation LPA interviewed the R1 and S1 and reviewed RP’s doctor’s orders. Allegation: Staff do not administer resident's medications. LPA reviewed a doctor’s order dated 6/28/24 addressed to the R1. The order states that the R1 “is able to manage their own medications when medications are presented to her in a Medication Blister Packs.” This agency has investigated the complaint alleging staff do not administer resident's medications. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted, a copy of this report provided. Unfoundedthe state’s words, verbatim · CDSS document, Jul 5, 2024 · control 15-AS-20240625163122

Allegation investigated: Staff do not accord resident privacy. Staff do not ensure resident's shower is in good repair.

On 7/05/2024 at 11:00 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Gaffar Syed, Administrator and explained the purpose of the visit. During the course of the investigation LPA interviewed the R1, S1 and S2. LPA also toured the shower room. Allegation: Staff do not accord resident privacy The R1 states that other facility residents wonder into her room “all day long.” The facility has many residents with dementia. S1 states the staff do their best to redirect residents to ensure that R1’s privacy is protected. LPA interviewed R1 in R1’s room for approximately an hour no other residents wondered into her room. R1 further stated that she closes her door more often and that helps. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** Allegation: staff do not ensure resident’s shower is in good repair. LPA toured the shower room with S1. LPA observed that there are three separate shower heads in the shower room. All three were in operating condition during the visit. R1 has a staff assisted shower. LPA interviewed S2 who assists R1 with her showers. S2 confirmed that there was issue with the shower hose being twisted which caused the water to stop flowing momentarily. S2 untwisted the hose and continued with the shower. This agency has investigated the complaint alleging staff do not accord resident privacy and staff do not ensure resident’s shower is in good repair. We have found that the complaints were unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 5, 2024 · control 15-AS-20240625163122

Allegation investigated: Staff do not ensure a safe environment is provided for residents.

On 6/19/24 at 10:00 a.m., Licensing Program Analysts (LPAs) Greg Clark and A. Gharachorloo arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegation above. LPA met with Gaffar Syed, Administrator and explained the purpose of the visit. During the investigation LPAs reviewed R1's facility file and interviewed S1 S2, and 2 residents (R2, R3). R1 was admitted to the facility on 5/16/24. Pre-appraisal documents state that R1 can become confused, anxious and agitated at times. On 6/1/24 while staff (S2) was attempting to administer R1 his PM medications he became very agitated and combative with S2. R1 hit the S2 on the face but there was no serious injury. 911 was called and R1 was transported to John George Psychiatric Hospital. R1 returned to the facility the following day. ***report continues on LIC9009C*** Unsubstantiated ***report continues from LIC9099*** On 6/10/24 R1 became argumentative with another resident (R3) wanting to take her snack. Staff intervened and R1 was redirected. However, another resident (R2) called 911, police arrived and R1 was taken to Summit Hospital and subsequently transferred to John George Psychiatric Hospital where he remains as of today. Doctors at John George are adjusting R1’s medications to lessen his anxiety and combativeness. S1 stated that the residents at the facility were never in any danger due to R1’s behaviors and that staff took appropriate action to redirect R1 to ensure the safety of the other residents. LPAs interviewed R2. R2 stated that she feared for the safety of the other residents and was unaware that staff were redirecting R1 to unsure the safety of the other residents. R2 also stated that she felt R1 was a “bad person” and should be living at the facility. LPAs interviewed R3. R3 stated that she was “very happy” living at the facility and that she has several friends whom she likes to socialize with. LPAs asked R3 about the incident involving R1 but R3 could not recall the incident. R3 also stated that she felt safe living at the facility. LPAs also interviewed S2. S2 stated that while attempting to give R1 his PM medications (S2 couldn’t recall the date) R1 grabbed the medications from her and threw them on the floor. He also grabbed the water cup and threw that as well. R1 also scratched S2 on her face. S2 declined medical attention. S2 also stated that feels “very safe” working at the facility. This agency has investigated the complaint alleging staff do not ensure a safe environment is provided for residents. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 19, 2024 · control 15-AS-20240611093513

Allegation investigated: Staff did not allow resident back to the facility

On 2/14/24 at 3:10 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver finding in regard to the allegations above. LPA met with Gaffar Syed, Administrator and explained the purpose of the visit. During the course of the investigation LPA interviewed the reporting party (RP), S1 and reviewed R1’s file including Unusual Incident Reports (UIRs). R1 was admitted to the facility on 6/25/22. On 11/17/23 R1 was transferred to Summit Hospital after a fall. While at the hospital R1 was diagnosed with c-diff. Summit Hospital discharged R1 to a rehabilitation facility on 11/23/23. On 12/06/23 facility staff went to visit R1 at the rehab facility. R1 was in isolation due to the c-diff. At that time, it was determined that R1 needed a high level of care ie: skilled nursing facility. ***report continues on LIC9099C*** Unsubstantiated ***Report continues from LIC9099*** The RP stated that she asked the facility to take R1 back until a SNF placement could be found. S1 told the RP that they could not take R1 back because her level of care is outside the scope of their license. This agency has investigated the complaint alleging staff did not allow resident back to the facility. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 14, 2024 · control 15-AS-20231218150828

Type of visit: Required - 1 Year

On 12/14/23 Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Gaffar Syed, Administrator and explained the purpose of the visit. The facility’s fire clearance was approved for 38. LPA toured the facility including but not limited to bedrooms, bathrooms, activity room, kitchen and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature in a residents’ shared bathroom was measured at 117.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 10/10/23. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 9/29/23. LPA reviewed 5 residents records and 5 staff records, all were complete. LPA also reviewed a sample of resident’s medications. During the visit LPA received an updated LIC610E Emergency and Disaster Plan and LIC9282 Infection Control Plan. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 14, 2023