Legacy Oaks of Sacramento

Type of visit: Office

On September 17, 2026, a virtual non-compliance conference was held via Microsoft Teams to discuss the substantial non-compliance history. The licensee has been cited forty-one (41) Type A deficiencies since licensure date of December 20, 2024. Present in today's meeting are Community Care Licensing (CCL) representatives: Regional Manager (RM), Stephenie Doub, Licensing Program Manager (LPM), Stephen Richardson, LPM Liza King, LPM Lisa Rios, Licensing Program Analyst (LPA), Christina Valerio, LPA Reza Jamaly, LPA Kimberly Viarella, and LPA Pang Lee; Long Term Care Ombudsman, Ron Carrera; Legacy Oaks of Sacramento Representatives: Licensee Shelly Cha, Licensee Christine Soriano, Regional Director Mery Lyn Otero, and Legal Counsel Jake Reinhardt This Noncompliance Conference was called to discuss the following issues or deficiencies: Forty-one (41) Type A Deficiencies Cited since licensed date of December 20, 2024, Incidental and Medical, Medications, Personnel Requirements - Training, Reappraisals, Basic Services, Activities, Transportation, Memory Care, Laundry Services, and Financial Monitoring effective 05/12/2026 Licensee agreed to do the following in order to bring the facility into compliance no later than the following dates: Submit copy of contract with Allen Flores Management Consulting by COB 10/02/2026 Submit Initial Training related to assessments for prospective Health and Wellness Coordinator by 10/02/2026 and then every six (6) months Submit copy of initial on-boarding staff training checklist by 10/02/2026 Continues on LIC 809 - C... Submit staff training regarding Assessments/ Reappraisals by 10/02/2026 and then every six (6) months Submit staff training regarding medications by 10/02/2026 and then every six (6) months Submit plan to address laundry services by 10/02/2026 Submit plan to address HVAC/ Air Conditioning System by 10/02/2026 Submit plan for activities and transportation services by 10/02/2026 Submit an updated emergency disaster plan by 10/02/2026 Submit copy of updated liability insurance by 10/02/2026 Submit copies of current invoices for USA Waste, SMUD, PG&E, and Consolidated Waste by 10/02/2026. Notify CCL of when Activity Director has been hired Licensee stated they have implemented training every other week. Licensee to provide these training to LPA during quarterly visit CCL will do the following: Continue increased quarterly monitoring for the next two (2) years Continue to collaborate with facility licensee and staff This report was read to Licensee Shelly Cha and Licensee Christine Soriano via cell phone. A copy of this report was provided via email with a signature request from the licensee. Licensee to send signed copy back to LPA Valerio.the state’s words, verbatim · CDSS document, Sep 17, 2026

Allegation investigated: Staff did not ensure that pets in the facility received adequate care and supervision.

On 08/27/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to complete and deliver the findings for the investigation into the above allegation. There were no management staff or front desk/concierge staff present at the facility when this LPA arrived at 8:30 AM, LPA proceeded down the main corridor and located 2 Medication Technicians. LPA identified herself upon and stated the purpose of the visit. Staff contacted management and this LPA went to sit in the front of the building to begin drafting observations. The Director of Memory Care arrived at approximately 9:00 AM and explained that their front desk person was out and they could not find coverage. The ED added, they recently hired a Business Office Manager and another Office Assistance so this sort of thing will not happen in the future. LPA requested a copy of the resident roster, a copy of the pet policy and list of all residents who owned dogs, as dogs were mentioned specifically in the complaint intake report. This LPA interviewed the Executive Director (ED), Donnabell Galicia, when they arrived. The ED could not produce any documentation regarding incidents or complaints involving dogs biting residents at the facility back in January 2026. Substantiated During the course of this investigation, this LPA reviewed the pet policy and interviewed 3 staff who were working at the time of the incident and 1 of the pet owners still residing at the facility. Out of the 4 individuals interviewed 3 stated that dogs were seen repeatedly off leash and that management did not address the issue. During this LPA's visit today, a dog was observed leaving a resident's room and walking toward the dining room. This was in direct violation of the Pet Policy which states under section 2: "Behavior and Supervision Requirements: Animals must be housebroken, socialized, and free from aggressive behavior(e.g. biting, growling). Pets must remain on a leash or in a carrier when outside a resident's private room and under direct adult supervision. Unsupervised animals are not permitted at any time." Section 1 Veterinary Clearance and Documentation states that, "All animals must present current vaccination records for rabies, distemper, and other regionally required immunization. Documentation must be submitted before the animal's entry and updated annually." The LPA and ED determined that a thorough review needed to be conducted to ensure that all pet documentation was up-to-date and copies were included in each resident's file. Based on interviews and observation, the facility has not been adhering to or enforcing its own pet policy. Animals have been in common areas of the facility off-leash, and the facility has not been ensuring that the animals living here are keeping their vaccinations current, therefore the Department found the allegation, "Staff did not ensure that pets in the facility received adequate care and supervision," SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit, a copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Galicia.the state’s words, verbatim · CDSS document, Aug 27, 2026 · control 27-AS-20260116171706

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208 · Plan of correction due date: Sep 10, 2026

87208 Plan of Operation (a) The licensee shall...maintain a ...plan of operation for the facility...may be cited for not doing so... The above requirement was not met as evidenced by: Based on 3 /4 interviews, dogs are in the common areas of the facility off-leash and Mgmnt has not been checking to ensure all vaccination docs are up-to-date and on file. This poses a potential threat to the health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2026

Plan of correction: ED stated that they will have a file review done to ensure all pet vaccinations are up-to-date and on file. ED stated they will request that the leash policy is added to the next resident council agenda. ED will review policy and have pet owners sign off on it. This will be emailed to CCL by 09/10/26

Allegation investigated: Staff does not ensure residents' care plan is up to date. Staff does not ensure resident is provided clean clothing. Staff does not ensure resident's hygiene needs are being met.

On 8/24/2026, Licensing Program Analyst (LPA) Reza Jamaly arrived unannounced at the facility to deliver the investigation findings regarding the allegations noted above. LPA met with Executive Director (ED) Donnabell Galicia and explained the purpose of the visit. As part of the investigation, LPA Jamaly conducted interviews, made observations of the facility and R1, and reviewed R1’s records. 1. Staff Does Not Ensure Residents’ Care Plans Are Up to Date On 8/24/2026, Licensing Program Analyst (LPA) Reza Jamaly interviewed R1’s sister, who is listed as Responsible Party 1 (RP1) and asked RP1 about the complaint. RP1 stated that I did not file the complaint, I learned about the complaint from the Executive Director (ED) and was informed that the complaint was filed by R1’s nephew. RP1 stated that R1 does not have a nephew. LPA asked whether RP1 had any concerns regarding R1’s care or whether R1 had any immediate needs at the facility. Unsubstantiated Page 2 RP1 stated that R1 has been receiving hospice services for approximately two months and had previously been hospitalized in the intensive care unit (ICU) for a period of time. RP1 stated that R1 is currently receiving the care and services needed and does not have any concerns at this time. RP1 stated that facility staff are taking care of R1 and that the ED contacts RP1 approximately once a week to provide updates regarding R1’s condition. RP1 also stated that a staff member recently contacted me and reported that R1 attempted to get out of bed at approximately 3:00 AM, to obtain a cigarette. LPA explained that R1’s access to cigarettes and a lighter was a concern reported by the facility and asked RP1 who provided R1 with the cigarettes and lighter. RP1 stated that I had provided R1 with cigarettes and a lighter but was subsequently instructed by facility staff not to do so. RP1 stated that I stopped providing cigarettes and a lighter to R1 after being instructed by staff not to do so. Based on R1 record, R1 is transported to Kaiser Permanente Emergency Department on 7/17/2026. The ER recommended follow-up with R1’s Primary Care Provider (PCP). No medication is prescribed during the ED visit. Hospice information is also provided in the discharge paperwork. On 7/21/2026, a comprehensive assessment was completed due to R1’s change in condition. The assessment identified R1’s primary diagnosis as Chronic Obstructive Pulmonary Disease (COPD) with acute lower respiratory infection and a mental health diagnosis of Major Depressive Disorder (MDD). The assessment indicated that R1 requires complete assistance with getting ready for bed, assistance with personal hygiene and grooming, and assistance with bladder incontinence, including assistance from two staff members. The assessment also indicated that staff are to complete skin checks at least twice weekly and as needed. R1 requires assistance with Activities of Daily Living (ADLs), is unable to stand or walk for extended periods, and uses a wheelchair. LPA Jamaly reviewed R1’s records and observed that R1’s Physician’s Report, LIC 602, was updated on 7/15/2026. The LIC 602 identified R1 as non-ambulatory and listed the following diagnoses: schizophrenia, urinary incontinence, nocturnal enuresis, acquired hypothyroidism, neurogenic bladder, chronic constipation, and other documented conditions. A TB clearance was completed on 7/11/2026. The LIC 602 also documented R1’s physical health status, including bowel and bladder incontinence, motor impairment/paralysis, and the need for assistance with repositioning and transfers. The report also indicated a history of skin conditions or breakdown. Page 3 On 8/13/2026, LPA Jamaly interviewed ED regarding the allegation. ED stated that some residents’ care plans had not been updated and that management was working to update them. However, regarding R1 specifically, ED stated that R1’s care plan had been updated. ED further stated that R1’s family requested that the facility accept R1 in hospice, and the facility requested that an assessment be completed prior to admission. Following the assessment, the facility accepted R1 and provided care while R1 was receiving hospice services. 2. Staff does not ensure resident is provided clean clothing. On 8/13/2026, LPA Jamaly conducted an observation and interview with R1. LPA observed R1 lying on the bed and receiving oxygen. R1’s bedroom door was open. During the interview, R1 requested that staff change R1’s brief. The caregiver was contacted and subsequently changed R1’s brief. LPA inspected R1’s bedroom and bathroom and observed the areas to be clean. LPA did not observe an odor of urine or feces in R1’s bedroom. During the interview, LPA experienced difficulty understanding R1. When questions were repeated, R1 became frustrated. LPA requested assistance from Staff 1 (S1) to facilitate communication. LPA asked R1 whether family members regularly checked on R1. R1 stated that R1’s sister and brother check on R1 and stated that R1 does not have a niece or nephew. LPA asked R1 how often R1’s briefs are changed, who assists with changing briefs and clothing, and when R1 last received a bath. R1 stated that R1’s briefs are changed approximately three times per day and pointed to S1 as the person who assists with changing R1’s briefs and clothing. R1 could not recall the exact date of the last bath but stated that it occurred a couple of days earlier. R1 denied experiencing a recent fall and denied having filed a complaint against the facility or staff. When asked about immediate needs or concerns, R1 stated, “I need emergency button. I don’t have one right now.” On 8/13/2026, LPA interviewed S1, and asked how frequently R1’s clothing and hygiene needs are checked. S1 stated that S1 works on the floor and changes R1’s briefs based on need. S1 stated that three other caregivers also assist with R1’s care. S1 stated that R1’s bedroom door is always open and that staff check on R1 frequently. S1 stated that R1 is not left in wet clothing or briefs. S1 stated that R1 receives baths based on need but does not take showers because R1 uses oxygen and is bedbound. Page 4 LPA asked S1 whether there were any concerns or needs regarding R1. S1 stated that R1 smokes and believed that R1’s brother and sister provide cigarettes. S1 stated that, on a previous occasion, a medication technician found a cigarette and lighter in R1’s possession. S1 also stated that R1 needs additional clothing, including pants, from the family or facility because the current clothing is stained. In an interview with Responsible Party 1 (PR1), LPA asked whether R1 had an adequate supply of clothing. RP1 stated that R1 has two bags full of clothing. RP1 explained that R1 is currently not using many of the clothes because R1 spends most of the time in bed. On 8/24/2026 LPA Jamaly interviewed S2 about handwritten laundry schedule provided by ED and asked if S2 confirm it. S2 confirmed it and stated that R1 laundry is done every Thursday. S2 added that R1 was changing clothes before frequently, but recently is not changing clothes a lot, because R1 is spending most of the time in bed, last Thursday, I just washed linen from R1. 3. Staff does not ensure resident's hygiene needs are being met. During LPA Jamaly’s observation on 8/13/2026, LPA inspected R1’s bedroom, bathroom, closet, and bed. R1 was observed receiving oxygen, and the bedroom door was open. LPA did not observe any apparent hygiene concerns and did not detect an odor of urine or feces in R1’s bedroom. During the interview on 8/13/2026, LPA asked R1 how frequently R1’s briefs are changed, who assists with the changes, and when R1 last received a bath. R1 stated that R1’s briefs are changed approximately three times per day and identified S1 as the person who assists with changing R1’s briefs and clothing. R1 stated that the last bath occurred a couple of days earlier but could not recall the specific date.When asked about immediate needs or concerns, R1 stated, “I need emergency button.”LPA also interviewed S1 regarding R1’s hygiene needs. LPA also interviewed S1 regarding R1’s hygiene needs. R1 stated that R1’s briefs are changed approximately three times per day and identified S1 as the person who assists with changing R1’s briefs and clothing. R1 stated that the last bath occurred a couple of days earlier but could not recall the specific date. When asked about immediate needs or concerns, R1 stated, “I need emergency button.” Page 5 LPA also interviewed S1 regarding R1’s hygiene needs. S1 stated that R1’s briefs are changed based on need and that three additional caregivers assist with R1’s care. S1 stated that staff check on R1 frequently and that R1 is not left wet. S1 further stated that R1 receives baths based on need but does not shower because R1 uses oxygen and is bedbound. LPA asked S1 whether S1 had observed any recent change in R1’s condition or any falls. S1 stated that S1 had not observed a change in condition or any falls involving R1. During interview with ED Regarding the allegations, ED stated that the facility recently terminated an employee and believed that the former employee may have submitted complaints on behalf of residents in retaliation. ED stated that, on a Friday, the police came to the facility and informed staff that an unknown individual had contacted law enforcement and identified sef as R1’s nephew when making the complaint. ED stated that the facility subsequently asked R1 about having a nephew. According to ED, R1 denied having a nephew and stated that R1 has only a brother and sister.LPA Jamaly also asked ED about the allegation concerning unreported falls involving R1. ED stated that R1 had not experienced any falls at the facility. LPA Jamaly searched the Department’s shared folder for incident reports involving R1 from March 2026 through 8/24/2026. No incident report documenting a fall involving R1 was located. Base on the observation, interviews and record review, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held and a copy of report provided to the facility.the state’s words, verbatim · CDSS document, Aug 24, 2026 · control 27-AS-20260811142302

Allegation investigated: Staff are not accepting resident back to facility.

This is a superseded report that includes supplimental information provided by Responsible Party1 (RP1) and reflects a change in the investigation findings from UNSUBSTANTIATED to SUBSTANTIATED. On 8/13/2026 at 9:40 AM, Licensing Program Analyst (LPA) Reza Jamaly arrived unannounced at the facility to deliver the complaint findings regarding the allegation listed above. LPA Jamaly met with the Memory Care Direct Shareetika Chand and explained the purpose of the visit. To investigate this allegation, LPAs conducted interviews, observed the facility, and reviewed relevant resident records, including medication records, incident reports, appraisal information, the admission agreement, and the resident's care plan. As part of the investigation, LPA Jamaly contacted the Reporting Party (RP). RP stated that R1 was transported to the hospital due to agitation on 3/17/2026 and again on 3/18/2026. RP stated that R1 was tested for a urinary tract infection (UTI) and prescribed medication. Substantiated Page 2 RP further stated that, the patient brought to hospital due to agitation on 3/17/2026 and then on 3/18/2026. Patient was tested for UTI and prescribed medication, and the resident didn't need 1:1 care after she we stabilized. I talked to them to accept the resident, follow the prescription order until you coordinate with responsible party or until another community care provider can be found, but they refused to accept her.” RP further stated that “you know it is hard to find a community care provider for residents who are on Medi-Cal. I wanted the resident to be accepted until another provider could be located and while coordinating with the responsible party and processing the eviction policy. I emphasized that the patient doesn't need 1:1 care and could be taken back to the facility, but they refused to accept her. On 3/24/2026 at 12:28 PM, LPA Christina Valerio received a telephone call from the facility's former Acting Administrator, Rosalie. Rosalie stated that R1 could not be accepted back from the hospital because R1 was not stabilized and the facility could not meet R1's needs at that time. Rosalie stated that R1 had been sent to the hospital after hitting staff members and was not at R1's baseline. Rosalie stated that she had requested documentation from the hospital but had not received the requested progress notes. Rosalie also stated that she had assessed R1 at the hospital and observed that R1 required a one-to-one sitter. Rosalie stated that the facility could not safely provide one-to-one staffing for R1. Rosalie further stated that she had spoken with the Long-Term Care Ombudsman (LTCO) regarding R1's situation. Rosalie stated that she wanted R1 to receive appropriate treatment and that the facility would accept R1 back if R1 returned at an assisted-living level of care that the facility could safely support. On 7/16/2026, LPA Jamaly interviewed the LTCO Sacramento Supervisor regarding the conversation described above. The LTCO Supervisor stated that he did not recall the specific conversation at that time and would review his records. He further stated that he was not in a position to agree or disagree with the facility regarding whether R1 could safely return to the facility. On 7/16/2026, LPA Jamaly interviewed staff 1 (S1). S1 stated that Resident 1 (R1) was so aggressive, ending up in hospital three times a week. I think R1 should not be admitted here because R1 was hitting care staff, another residents, refusing medication, and was eloping. We changed R1 room to prevent hitting other residents, but it did not work. page 3 S1 added that on 3/18/2026 I witnessed R1 hit paramedic in the head with a vase when Alpha one trying to transport her to ER and in another incident R1 eloped and was found near Target store. S1 does not remember the exact date of R1 eloping. LPA Jamaly interviewed Executive Director (ED) Donnabell. ED stated that she was not employed at the facility at the time of the incident. However, based on discussions with facility staff, ED understood that R1 had not been formally evicted but was not accepted back because the facility determined that it could not meet R1's needs, specifically the need for continuous one-to-one staffing. On 8/10/2026, LPA Jamaly interviewed Responsible Party 1 (RP1) regarding the allegations. RP1 stated that the facility did not notify RP1 regarding R1's eviction or the facility's decision not to accept R1 back. RP1 stated that RP1 learned about the situation through Kaiser Permanente Hospital. RP1 stated that R1 had resided at the facility for approximately five years and had become increasingly combative after not receiving prescribed medications. RP1 also stated that the facility had failed to properly submit R1's paperwork to Social Security and Medi-Cal, which resulted in the loss of benefits. RP1 stated that RP1 eventually assisted R1 in reinstating the benefits. RP1 stated that Kaiser Permanente assisted in locating another facility for R1, where R1 is currently receiving medications and doing well. RP1 denied that R1 lacked adequate clothing and stated that RP1 had purchased multiple sets of clothing and other personal belongings for R1. RP1 stated that, after R1 left the facility, the facility did not return R1's clothing and personal belongings. Regarding the allegation that the facility did not accept R1 back, RP1 stated that the allegation was true. RP1 stated that the facility repeatedly sent R1 to Kaiser Permanente due to aggressive behavior, including one occasion when R1 remained hospitalized for approximately two months. RP1 also reported frequent changes in facility management and staff and stated that the facility did not provide appropriate care or adequately manage R1's paperwork. LPA Jamaly reviewed incident reports documenting multiple incidents involving R1's aggressive behavior and refusal of medications. page 4 LPA Jamaly reviewed R1's Medication Administration Records (MARs). The records indicate that R1 refused multiple scheduled medications during March 2026, including morning and afternoon medications on numerous dates. The records also document that R1 was transported to Kaiser Permanente on 3/16/2026, 3/17/2026, and 3/18/2026 due to agitation and aggressive behavior. An Incident Report documented that on 3/18/2026, R1 became aggressive and hit a care staff member. Alpha One was called to assist, and R1 subsequently struck a paramedic in the head with a vase. The report stated that Alpha One personnel restrained R1 and transported R1 to Kaiser Permanente Emergency Room for evaluation. LPA Jamaly reviewed R1's LIC 602A. The document indicates that R1 had diagnoses including schizophrenia, insomnia, constipation, muscle weakness, and dementia, with ongoing agitation and aggressive behaviors. LPA Jamaly reviewed R1's Admission Agreement. The agreement states that the facility may terminate the admission upon 30 days' written notice when, following reassessment, it is determined that the facility is no longer appropriate for the resident. LPA Jamaly did not locate documentation showing that a 30-day written notice was provided to R1 or RP1 regarding the facility's decision not to accept R1 back. Additionally, based on interviews conducted during the investigation, the facility did not notify RP1 regarding its decision not to accept R1 back to the facility. LPA Jamaly reviewed R1's Preplacement Appraisal Information, LIC 603. The document indicates that R1 was unable to follow signals and required assistance with toileting, medication, and health and medical care. Based on interviews, records reviewed, the preponderance of evidence establishes that the facility did not accept R1 back from the hospital and did not provide evidence that the required eviction/discharge process had been properly followed or that RP1 had been provided the required notice. Therefore, this allegation is Substantiated. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Executive Direct Donnabell Galicia and a copy this report and appeal rights provided to facility. Page 2 RP acknowledged that R1 had been diagnosed with a UTI but stated that RP was not alleging that the UTI resulted from inadequate care. On 8/10/2026, LPA Jamaly conducted phone interview with S2 and asked whether R1's toileting, grooming, and hygiene needs were adequately met. S2 stated that, generally, caregivers were responsible for meeting R1's needs despite significant staff turnover. S2 also stated that R1 frequently refused care, attempted to elope, and became aggressive when caregivers attempted to assist R1 with hygiene needs. S2 stated that R1 would sometimes slam the door and become aggressive toward staff. LPA asked S2 whether S2 observed any changes in R1's urine or other signs of a UTI. S2 stated that S2 did not observe changes in R1's urine and did not observe signs of a UTI at that time. LPA asked how frequently R1 was expected to be toileted or have briefs changed. S2 stated that R1 was expected to receive assistance approximately every two hours. When asked whether inadequate care resulted in R1 developing a UTI, S2 stated that S2 did not believe the UTI was caused by staff negligence. On 8/10/2026, LPA Jamaly interviewed S3. LPA asked whether R1's grooming and toileting needs were met. S3 stated that S3 was unsure because R1 was frequently aggressive, and other staff were sometimes reluctant to provide care. S3 stated that R1 was more receptive to assistance from S3 and that S3 assisted R1 with changing briefs, showering, and other personal care needs. S3 also stated that management requested S3's assistance when R1 eloped. S3 stated that R1 frequently refused care. When asked what management did when R1 refused services, S3 stated that management considered refusal of services to be R1's right. LPA asked S3 whether S3 believed inadequate care resulted in R1 developing a UTI. S3 stated that S3 was unsure. S3 reported observing messes in R1's room when attempting to provide care and stated that R1 was not receptive to assistance from other staff. S3 also stated that R1's personal hygiene declined over time. S3 reported observing that R1 sometimes went several days without changing clothes and believed that R1 may not have had sufficient clothing available. LPA reviewed R1's LIC 602A, dated 9/24/2025. The document indicates that R1 was unable to independently meet toileting needs but was not bowel or bladder incontinent. Page 3 LPA reviewed R1's Care Plan, dated 2/3/2026. The care plan indicates that R1 required total assistance with personal hygiene and grooming and that staff were to complete skin checks at least twice per week, as needed. The care plan further documents that R1 did not consistently use the toilet and demonstrated inappropriate toileting behaviors, including urinating on the floor, furniture, or bed. The care plan states that R1 refused to wear incontinence products and was noncompliant with perineal care and cleanup following toileting incidents. Staff were directed to provide verbal prompts, physical assistance as tolerated, redirection, and environmental cleaning to maintain sanitary conditions and reduce the risk of infection. The care plan also indicates that R1 was physically able but unmotivated to participate in grooming, bathing, and incontinence care and frequently declined assistance or became resistant when prompted. Staff were directed to provide frequent reminders, redirection, and supportive encouragement. LPA also reviewed R1's LIC 603, which indicates that R1 required assistance with bathing, toileting, hair care, and personal hygiene. 3. Staff don't answer facility phone. On 5/26/2026, RP returned LPA Jamaly's telephone call. When asked about this allegation, RP stated that the hospital had contacted the facility multiple times regarding R1's pending discharge and current status. RP stated that facility staff did not answer the telephone, which caused frustration. On 7/16/2026 at 10:26 AM, LPA Jamaly called the facility's telephone number, (916) 482-7745. The call was answered by the front desk. LPA Jamaly called the facility again at 1:04 PM on the same date, and the call was also answered by the front desk. LPA Jamaly asked ED to provide telephone logs for the period of 3/16/2026 through 3/23/2026. ED stated that there had been significant changes at the facility since March 2026 and that the facility had more than one telephone number. Page 4 On 7/16/2026, LPA Jamaly attempted to contact RP to determine which facility telephone number RP or the hospital had contacted. RP did not answer the call. Although RP reported that the hospital had difficulty reaching the facility, the investigation did not establish which telephone number was called, the dates and times the calls were made, whether the calls were received by the facility, or whether facility staff intentionally failed to answer the calls. Based on interviews, observations, and records reviewed, the preponderance of evidence standard is not met. Therefore, the allegations are UNSUBSTANTIATED. A finding of unsubstantiated means that the allegation may have occurred or may be valid; however, the evidence does not establish by a preponderance of the evidence that the alleged violation occurred. An exit interview was conducted with Executive Direct Donnabell Alicia and a copy this report and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Aug 13, 2026 · control 27-AS-20260323125642

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(a)(4) · Plan of correction due date: Sep 1, 2026

87224 Eviction Procedures. The licensee may evict a resident for one or more of the reasons... Thirty (30) days written notice to the resident is required..If, after admission, it is determined that the resident has a need not previously identified.. This requirement is not met as evidenced by: Baed on interviews conducted and records reviewed, the licensee didn't comply with section cited above because eviction procedures were not followed and the resident evicted without providing 30 days written notice to the resident.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: The Administrator/Licensee will review 87224 Eviction Procedures and Facility Eviction Policy/Admission Agreemtn and sign a statement stating revision completed. Administrator/Licensee provide training regarding eviction procedures and provide proof of training competion including trainee's name with thier signature, date of traiing and training title.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced on 08/06/2026 to conduct a case management visit. LPA Lee met with Executive Director (ED) Donnabell Galicia and explained the purpose of the visit. The facility census was 77 residents. The purpose of today's visit was to follow up on SOC 342, Report of Suspected Dependent Adult/Elder Abuse received by the Department on 08/03/2026. According to the report, on July 29, 2026, at approximately 4:00 p.m., Resident 1 (R1) reported alleged financial abuse involving former Director of Marketing (DOM). It was alleged that approximately $3,500 had been stolen from R1’s bank account. R1 reported that DOM frequently transported R1 to the bank on approximately 8 to 10 occasions and retained possession of R1’s bank card. It was also alleged that DOM wrote down R1’s personal identification number (PIN) and stated that R1’s bank records reflect multiple late-night withdrawals and that DOM signed the resident out of the facility, transported the resident to the bank, and signed the resident back into the community after the transactions. It was laterad learned that the resident closed the bank account and opened a new bank account and obtained a new bank card to prevent further unauthorized access. During the visit, LPA Lee requested the following documents to assist with the investigation: · Current LIC 500 Personal Report · Current Resident Roster · LIC 601 Identification and Emergency CONTINUED LIC 809-C · LIC 625 Appraisal and Needs and Service · LIC 601 Physician Report · Charting Notes/Care Notes · LIC 604 Admission Agreement · LIC 621 Client/Resident Personal Property and Valuables · LIC 400 Affidavit Regarding Client/Resident Cash Resources · LIC 405 Records of Residents Safeguarded Cash Resources Based on the information obtained and interviews conducted during today's case management visit, this needs further investigation. LPA Lee will follow up this incident at a later date. An exit interview was conducted with ED Galicia A copy of this LIC 809 report was provided to ED Galicia at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 6, 2026

Allegation investigated: Questionable death

On 07/10/2026, at 8:40 AM, Licensing Program Analyst (LPA) Kimberly Viarella made an unannouced visit to this facility to deliver the findings of this investigation. LPA identified herself, stated the purpose of the visit and asked to meet with the Designated Facility Administrator/Executive Director (ED), Donnabell Galicia. There were no members of management present. There were 2 Medication Technicians (MedTechs) working in the assisted living side, 2 Care Staff in Assisted Living and 3 Care Staff in Memory Care. When asked for access to an empty room to work in, MedTech working just off the lobby told this LPA that they did not have keys to access those rooms but that managment would be in shortly. The Director of Memory Care arrived at approximately 9:00 AM and provided this LPA with a private room to work in and the ED arrived shortly after and spoke to the LPA regarding a plan of correction submission. Regarding the Allegation: Questionable death The Death Certificate was obtained and indicates that the resident's (R1's) immediate cause of death as cardiac arrest and the leading causes as diabetes, hypertension, hyperlipidemia. R1's death was Unsubstantiated reported to the Sacramento County coroner's office and no autopsy was performed. The death certificate does not indicate that this death was questionable in any manner. The above allegation is 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. According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit, a copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Galicia. The following deficiency, 87506 (a) was cited per California Code of Regulations, TITLE 22, DIVISION 6, CHAPTER 8 Article 9 and may be found on the LIC 9099D page. During her tour of the facility, LPA observed that the Medication Technician was administering morning 8:00 AM Medications at 10:00 AM in Memory Care. A case management visit will be conducted following this one to address this deficiency. Exit interview was conducted with the ED, Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 10, 2026 · control 27-AS-20251103152307

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Sep 17, 2026

Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each...facility...readily available to facility staff and to licensing agency staff. The above requirement was not met as evidenced by: Based on record review, 7/ 8 resident files did not have the resident PRN authorization form. 3/8 residents were missing Personal Rights forms. 1/8 residents was missing identification and emergency information form. This posed a potential threat to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jul 10, 2026

Plan of correction: ED stated they will complete a resident file audit. LPA to provide list of documents/information required for each resident. The audit report will be submitted to Licensing by close of business on 09/17/26 by emailing CCLASCPSacramentoSouthRO@dss.ca.gov

Type of visit: Case Management - Deficiencies

On 07/10/2026, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator / Executive Director (ED). LPA met with Donnabell Galicia and a brief interview followed. LPA arrived at this facility at 8:40 AM prior to management arriving. LPA observed one of the 2 Medication Technicians administering medications to residents in Assisted Living (AL). The Director of Memory Care arrived and provided this LPA a private room to prepare for delivering the findings to complaint investigation # 27-AS-20251103152307. Prior to meeting with the ED, this LPA took an independent tour of the facility. When the LPA arrived in Memory Care (MC) it was approximately 10:00 AM. LPA observed a Med Tech (M1) administering medications. LPA could see the screen and the resident they were administering medications to was supposed to have their medications at 8:00 AM. LPA noticed that MC was quieter than usual and the MedTech explained that many of the residents were taken to the Assisted Living area for a "Coffee Hour." M1 went on the say that they would go there after finishing up in MC to ensure that everyone got their morning medications. LPA requested the EMAR for 3 residents in MC (R1-R3). Upon record review R1 was administered their 6 different 8:00 AM medications at 10:20 AM. R2 was administered their 8:00 AM medication at 10:01 AM. R3 was not administered their 5 different 8:00 AM medications at all. The report presented for review was printed at 3:30 PM today. This LPA shared this information with the ED. This deficiency has been cited on the LIC 809D page. According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit a copy of this report was provide along with APPEAL RIGHTS and an exit interview was conducted with Galicia.the state’s words, verbatim · CDSS document, Jul 10, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 11, 2026

(a) A plan for incidental medical and dental care shall be developed... (4) The licensee shall assist residents with self administered medications as needed. The above requirement was not met as evidenced by: Based on record review, 3 out 3 residents did not receive their medications as prescribed. This posed an immediate risk to the health safety and personal rights of residents at risk.the state’s words, verbatim · CDSS document, Jul 10, 2026

Plan of correction: The ED and the Memory Care Director will be shadowing the MedTechs to ensure accuracy and provide training, They will also be reviewing the Med Pass report and using that as a training base. They will provide a pictures with time stamps during this shadowing and submit them to licensing at CCLASCPSacramentoSouth@dss.ca.gov.

Allegation investigated: Staff do not answer resident call buttons in a timely manner. Staff are not administering medications as prescribed.

On 07/08/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to address omissions in the report delivered on 05/15/26 for complaint # 27-AS-20250915145921. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator/Executive Director. LPA met with Donnabell Galicia and a brief interview followed. The purpose of the report was explained. LPA Viarella substantiated 3 allegations, but cited only for one. This LPA has returned to address the substantiated allegations above. Regarding: "Staff do not answer resident call buttons in a timely manner." This allegation was substantiated during the same investigation window in complaint #27-AS-20250910090018, and the allegation was cited on 09/10/25. The same allegations, cited within 5 days of each other do not incur a second citation. Substantiated Regarding: Staff are not administering medications as prescribed. This LPA reviewed the Electronic Medication Record for R1 for the month of August 2025, and learned that R1 was not administered the following medications: BUSPIRONE 10MG TABLET – 2 times DAPAGLIFLOZIN 10MG TABLET – 3 times DIVALPROEX SOD DR 250MG TABLET – 9 times GABAPENTIN 400MG CAPSULE – 1 time INCRUSE ELLIPTA 62.5MCG BLST W/DEV – 1 time LANTUS SOLOSTAR 100UNIT/1ML INSULN PEN – 1 time LISINOPRIL 10MG TABLET – 2 times MIRTAZAPINE F/C 45MG TABLET – 4 times NICOTINE PATCH STEP 1 21MG24H PATCH TD24 – 5 times To summarize, R1 was not administered prescribed medications 28 different times during the month of August 2025. The facility failed to ensure that R1’s prescribed medications were available for administration. As a result, the resident missed ordered doses when medication was not timely ordered/and or obtained from the pharmacy. This deficiency has been cited on the LIC 9099D page. According to the California Code of Regulations Title 22, no other citations were cited during this visit, a copy of this report was provided along with APPEAL RIGHTS, and an exit interview was conducted with Galicia.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 27-AS-20250915145921

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jul 9, 2026

87465 (a) A plan for incidental medical ... and provide for assistance in obtaining such care...(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. Based on a review of records, R1 was not administered prescribed medications 28 different times during the month of August, 2025. This posed an immediate threat to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2026

Plan of correction: The Executive Director (ED) stated that they are condcuting med tech training on a monthly basis. ED will send a draft of monthly trainings for the next 6 months to this LPA at Kimberly.viarella@dss.ca.gov by the COB 07/09/26.

Type of visit: Case Management - Deficiencies

On 07/08/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management meeting. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator/Executive Director. LPA met with Donnabell Galicia and a brief interview followed. During the course of the investigation into complaint # 27-AS-20250915145921, this LPA learned that a resident, (R1) was administered PRN medications (prescription medications on an as needed basis). Facility staff logged that the medications were administered, however this LPA observed that the effectiveness of R1’s PRN medication, OXYCODONE-ACET 10MG-325MG TABLET, was not documented once on 08/10/25, twice on 08/29/25 and once on 08/30/25. Staff also did not record the effectiveness of a dose of ALBUTEROL SULF 25’S (BX) on 08/10/25. This deficiency was cited on the LIC 809D page. There were no other deficiencies cited during today's visit, a copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Galicia.the state’s words, verbatim · CDSS document, Jul 8, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(13) · Plan of correction due date: Aug 31, 2026

87506 Resident Records (b) Each resident’s record shall contain...(13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services. The above requirement was not met as evidenced by: Based on record review, staff did not log the effectiveness of PRN medications 5X during August 2025. This posed a potential threat to the health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2026

Plan of correction: The Executive Director (ED) has assiged MedTechs to specific residents. The ED will verify by auditing the PRN logs with each staff member and reporting to licensing by COB 08/31/26.

Allegation investigated: Managers instruct staff to lie to licensing

On 7/7/2026 Licensing Program Analysts (LPAs) Reza Jamaly and Christina Valerio arrived unannounced at this facility to submit the finding of investigation about allegation noted above. LPAs met the Executive Director (ED) Donnabell Galicia and stated the purpose of the visit. Reporting Party (RP) is anonymous and could not be contacted. To investigate the allegation, LPAs conducted interviews with staff and managers. On 7/7/2026 LPA Reza Jamaly called staff 1 (S1) and asked about allegation above. S1 stated that S1 is not being instructed by managers to lie to licensing department and has not been witnessed that managers instruct other staff to lie to licensing. S1 added that S1 is working 5 days a week 8 hours each for both assisting living and memory care wings. On 7/7/2026 LPA Reza Jamaly called staff 2 (S2) and asked about allegation above. S2 stated that S2 is not instructed by managers to lie to licensing and has not been witnessed that managers instructed other staff to lie or give false information. Continues on LIC 9099C on page 2 Unsubstantiated S2 also stated that I have heard that it was happening in the past and S2 is new to this job but currently S2 is not witnessing. S2 added that when the state is here, managers are showing that everything is fine but it is not. LPA asked to give more information or give any instances that things were not fine but reported fine. S2 raised concern about ACs and mentioned that sometimes temperature is above 90 degree, they are using cooler but they are not working properly. On 7/7/2026 LPA Jamaly interviewed Executive Director (ED) Donnabell about above allegation. ED denied the allegation and stated " that I clearly explained the reporting policy all the time and most recently on staff meeting held on 6/30/2026 I told to the staff that when licensing here, I will put my hands up, if you are asked you should report what you observe and tell the truth. Keep the door open to licensing, they will find what they observe. Licensing is most often here, they will inspect everywhere they want and there is nothing to hide. Based on the interview with staff and manager, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held and a copy of report provided to the facility.the state’s words, verbatim · CDSS document, Jul 7, 2026 · control 27-AS-20260625141905

Allegation investigated: Staff dropped a resident Staff made inappropriate comments about a resident

On 7/2/2026 at 9:00 AM, Licensing Program Analysts(LPA), Reza Jamaly arrived unannounced to continue with the complaint investigation and deliver findings regarding the allegation noted above. LPA initially met with staff on duty and explained the purpose of the visit. The administrator, Donnabell Alicia, was notified of the visit and arrived shortly after. Allegation: Staff dropped a resident To investigate the allegation, LPAs conducted interviews and reviewed resident's file. LPAs reviewed incident's reports for the month of March and February 2026 , No fall incident report documented during R record review. LPA Jamaly contacted R1's responsible party (RP) via phone number on file, introduced self and explained the purpose of the call, RP stated that R1 passed away, when asked about the allegations, RP stated that RP don't know specifically about the incident but the facility is terrible. Continue on LIC 9099C on Page 2... Unsubstantiated Page 2 When asked if RP can provide more information, RP mentioned that "it's all done I don't want to talk about it anymore, I gotta go, bye bye" and hanged up the phone. LPA Jamaly also called R1's emergency contact number on file, someone picked up the phone, LPA introduced self and explained the purpose of the call. The other side stated" you have called the wrong number". LPA reviewed LIC 602A dated 10/29/2025. R1 is marked as ambulatory at this time with dementia diagnosis, but needs assistance to perform activities of daily living (ADLs), including: Waking, bathing, dressing/grooming, feeding , toileting and medication management. LPA reviewed R1 assessment (change of condition) dated 1/31/2026 and ambulation status changed to non-ambulatory. Based on this document R1 uses a device to ambulate and needs a 1 person assist to use the device. LPAs also reviewed incidents report for February and March 2026, no incident of abuse reported about R1. Allegation: Staff made inappropriate comments about a resident LPA contacted responsible party (RP), RP was not aware of the incident, and just stated that R1 is passed away on June 15, 2026 and the facility was terrible. RP didn't wanted to continue answering LPAs additional questions. LPA Jamaly contact 3 out 5 housekeeping staff (S1, S2, S3, S4). S1 was not aware of the incident and hasn't heard about it from others. LPA contacted S2, S2 had hard time understanding English and interview was unsuccessful. LPA interview S4 about R1's incident fall and stated that S4 was not working at that day. S4 added that R1 was refusing the medication, and was saying nasty word to medication technician during medication time. S4 added that R1 was lashing out and didn't wanted to be at the facility. When asked if any staff was treating R1 inappropriately or saying inappropriate word, S4 stated that we had a medication technician who was straight forward/blunt to R1 when refusing the medication but S4 did not witnessed staff saying inappropriate words. Based on LPA observations, interviews conducted, and records reviewed, the preponderance of , the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 27-AS-20260306103816

Allegation investigated: Staff did not ensure that resident took medication as prescribed

On 6/30/2026 at 9:30 AM, Licensing Program Analysts (LPAs) Reza Jamaly and Christina Valerio conducted an unannounced visit to the facility to continue the investigation of the above allegation. Upon arrival, LPAs met with Executive Director (ED) Donnabell Galicia and explained the purpose of the visit. During the investigation, LPAs conducted interviews, reviewed resident records, and attempted to contact the resident's Reporting Party (RP) by telephone and email. LPAs reviewed Resident 1's (R1's) Medication Administration Record (MAR) for February, March, and April 2026. HYDROcodone-Acetaminophen 5-325 mg (Norco) was administered as 2 tablets twice daily, with staff initials documenting each administration. LPAs then reviewed the March 2026 MAR and observed that no medication administration was documented from 3/1/2026 through 3/9/2026. Beginning 3/10/2026 through 5/21/2026, the MAR reflected administration of HYDROcodone-Acetaminophen 10-325 mg, 1 tablet twice daily, indicating a change in medication dosage. Continues on LIC 9099C on page 2 Substantiated page 2 At the time of the review, the facility was unable to provide a physician's order authorizing this medication change. LPAs requested R1's current physician's report during the investigation. On 3/24/2026, the facility provided a LIC 602 dated 11/10/2023. Since the document was not current, LPA Jamaly requested an updated physician's report, along with any physician's orders or supporting documentation authorizing the medication change, via email on 5/21/2026 and sent follow up email on 6/29/2026 to ED Donnabel Galicia and Memory Care Director, Shareetika Chand. As of the date of this report, the facility had not provided a physician's order or other documentation authorizing the medication change reflected on the MAR. LPA Christina attempted to contact the Reporting Party (RP) via telephone on 3/24/2026 and on 5/21/2026 Reza Jamaly attempted again and also sent an email on 5/21/2025 requesting clarification and supporting information, however, no response was received from RP by conclusion of the investigation. LPAs also reviewed R1's Individual Service Plan, annual appraisal dated 2/5/2025, and Admission Agreement dated 12/2/2023. These records documented that R1 required assistance with medication administration and that facility staff were responsible for assisting R1 with taking medications as prescribed. Based on interviews, record reviews, and the facility's failure to provide documentation supporting the medication change, the Department has determined, by a preponderance of the evidence, that the allegation is SUBSTANTIATED. A deficiency is cited under California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87465(e), Incidental Medical and Dental Care. An exit interview was held with Administrator Donnabell Galicia, and a copy of report was left at the facility. Appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 27-AS-20260318085351

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Jul 1, 2026

87465 Incidental Medical and Dential Care (e)For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician...This requirement was not met as evidenced by: Based on the observation, interview and record review, the licensee didn't ensure that R1's medication is administered as prescribed by physician which posess an immediatel health, safety and personal risk to person in care.the state’s words, verbatim · CDSS document, Jun 30, 2026

Plan of correction: The licensee will provide medication training to relavent staff and will send a copy of training certificate of complation to LPA by July 1, 2026.

Allegation investigated: Staff did not ensure that resident took medication as prescribed

On 6/30/2026 at 9:30 AM, Licensing Program Analysts (LPAs) Reza Jamaly and Christina Valerio conducted an unannounced visit to the facility to continue the investigation of the above allegation. Upon arrival, LPAs met with Executive Director (ED) Donnabell Galicia and explained the purpose of the visit. During the investigation, LPAs conducted interviews, reviewed resident records, and attempted to contact the resident's Reporting Party (RP) by telephone and email. LPAs reviewed Resident 1's (R1's) Medication Administration Record (MAR) for February, March, and April 2026. HYDROcodone-Acetaminophen 5-325 mg (Norco) was administered as 2 tablets twice daily, with staff initials documenting each administration. LPAs then reviewed the March 2026 MAR and observed that no medication administration was documented from 3/1/2026 through 3/9/2026. Beginning 3/10/2026 through 5/21/2026, the MAR reflected administration of HYDROcodone-Acetaminophen 10-325 mg, 1 tablet twice daily, indicating a change in medication dosage. Continues on LIC 9099C on page 2 Substantiated page 2 At the time of the review, the facility was unable to provide a physician's order authorizing this medication change. LPAs requested R1's current physician's report during the investigation. On 3/24/2026, the facility provided a LIC 602 dated 11/10/2023. Since the document was not current, LPA Jamaly requested an updated physician's report, along with any physician's orders or supporting documentation authorizing the medication change, via email on 5/21/2026 and sent follow up email on 6/29/2026 to ED Donnabel Galicia and Memory Care Director, Shareetika Chand. As of the date of this report, the facility had not provided a physician's order or other documentation authorizing the medication change reflected on the MAR. LPA Christina attempted to contact the Reporting Party (RP) via telephone on 3/24/2026 and on 5/21/2026 Reza Jamaly attempted again and also sent an email on 5/21/2025 requesting clarification and supporting information, however, no response was received from RP by conclusion of the investigation. LPAs also reviewed R1's Individual Service Plan, annual appraisal dated 2/5/2025, and Admission Agreement dated 12/2/2023. These records documented that R1 required assistance with medication administration and that facility staff were responsible for assisting R1 with taking medications as prescribed. Based on interviews, record reviews, and the facility's failure to provide documentation supporting the medication change, the Department has determined, by a preponderance of the evidence, that the allegation is SUBSTANTIATED. A deficiency is cited under California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87465(e), Incidental Medical and Dental Care. An exit interview was held with Administrator Donnabell Galicia, and a copy of report was left at the facility. Appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 27-AS-20260318085351

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Jul 1, 2026

87465 Incidental Medical and Dential Care (e)For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician...This requirement was not met as evidenced by: Based on the observation, interview and record review, the licensee didn't ensure that R1's medication is administered as prescribed by physician which posess an immediatel health, safety and personal risk to person in care.the state’s words, verbatim · CDSS document, Jun 30, 2026

Plan of correction: The licensee will provide medication training to relavent staff and will send a copy of training certificate of complation to LPA by July 1, 2026.

Type of visit: Case Management - Deficiencies

On 6/30/2026 at 9:30 AM, Licensing Program Analysts (LPAs) Reza Jamaly and Christina Valerio conducted an unannounced visit to the facility to continue the investigating a complaint. Upon arrival, LPAs met with Executive Director (ED) Donnabell Galicia and explained the purpose of the visit. During the complaint investigation process, LPAs reviewed file for Resident 1 (R1) and noticed that there is no LIC 602 for R1 on file. LPA interviewed with ED Dannoabell Galicia on 6/11/2026, she stated that she was recently hired as the facility's Executive Director and had limited knowledge regarding resident records and facility operations that occurred before her employment. LPA Reza Jamaly sent an email to Memory Care Director Shareetika on 5/21/2026 and followed up on 6/29/2026 asking for updated LIC 602, however the facility failed to provide an updated LIC 602 for R1. In an interview with Memory Care director Shareetika, she state that we requested updated LIC 602 from R1's PCP via email and fax but received no response yet. Based on interviews, and file receive, facility failed to maintain an LIC 602 in R1 file. A deficiency is cited under California Code of Regulations, Title 22, Division 6, Chapter 8, 87506 (a) . An exit interview was held with Administrator Donnabell Galicia, and a copy of report was left at the facility. Appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 30, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Jul 7, 2026

87506 Resident Records(a).The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility... This requirement was not met as evidenced by: Based on the observation, interview and record review, the licensee didn't ensure that an updated physician report is maintained in R1 file since 2023 which poses a potential health, safety and personal risk to person in care.the state’s words, verbatim · CDSS document, Jun 30, 2026

Plan of correction: The licensee will make sure the updated LIC 602 is maintained in R1 file by July 15, 2026. Licensee will send a copy of LIC 602A to LPA by due date.

Allegation investigated: Staff are not ensuring residents are bathed Staff are not providing shower chairs for residents Staff are not providing a clean environment for residents Staff are not providing adequate laundry services for residents Staff are not providing adequate incontinence care for residents Staff are not preventing a roach infestation in the facility Licensee is not ensuring adequate staffing to meet residents' needs

On 6/26/2026 Licensing Program Analysts (LPAs) Reza Jamaly and Christina Valerio arrived unannounced at this facility to conduct the initial complain investigation regarding the allegations noted above. LPAs met the Executive Director (ED) Donnabell Galicia and stated the purpose of the visit. LPA Jamaly and Valerio took a tour to the Memory Care wing assisted by Memory Director Shareetika Cha. Allegation: Staff are not ensuring residents are bathed LPAs conducted interview, reviewed files and took tour to the facility to investigate the allegation above. Firstly, LPAs toured to memory care wing hallway, dining room and pantry attached to the dining room, laundry room, and kitchen and checked 6 rooms out of 12 rooms and observed to be clean and sanitary. LPA conducted attempted interview with 3 residents (R1), (R2) and observed two residents in which one of them were sleep, and (R3) to ask about above allegation, it was unsuccessful and they didn't talk or were not able to talk. Continued on page 2 LIC 9099C Unsubstantiated Page 2. LPA reviewed care plan/services plan of 6 residents (R1, R2, R3, R4, R5, R6) and observed that bathing assistance, housekeeping assistance, and laundry assistance is scheduled on different dates. LPA also reviewed showering log for 6 residents (R1, R2, R3, R4, R5, R6), which were signed and dated by S1 on 6/23/2026, 6/20/2026, 6/20/2026, 6/19/2026, 6/18/2026, 6/16/2026. To confirm if the log is correct, LPA interviewed S1, S1 stated that each resident take shower two times a week unless they refuse to do. Allegation: Staff are not providing shower chairs for residents LPAs toured 6 residents’ bathrooms and six out of six rooms were observed to have shower chairs. Some bathrooms were observed to have boosters as well. Memory Care director Shreetika stated that boosters are provided based on the residents’ needs. LPA Jamaly interviewed S1 and S1 confirmed that residents who needs shower chair,they have in their bathrooms. Allegation: Staff are not providing a clean environment for residents During the facility observation and tour to the Memory Care wing, LPA toured to hallways, 3 laundry rooms, dining/activity room and pantry attached to the dining, kitchen and checked 6 out of 12 bedrooms, which all areas observed to be clean and sanitary. One housekeeper was observed to be cleaning the dining room. Allegation: Staff are not providing adequate laundry services for residents To investigate above allegation, LPA toured to the laundry rooms. Total there are three laundry rooms at the facility. Laundry room 1 with one washing machine for Memory Care, laundry room 2 with 1 washing machine for Assisted Living (AL) wing and one large laundry room 3 with two washing machine for both AL and Memory Care. LPAs observed that the washing machine for memory care was non operational. During the interview with Memory Care director Tikka, she stated that it stopped working on 6/25/2026 around 4 PM and she immediately called the technician Eizel Corpuz to fix it. Technician scheduled to fix it today 6/26/2026. LPA also, observed the communication between memory director and Eizel regarding fixing the laundry. Allegation: Staff are not providing adequate incontinence care for residents Reporting Party (RP) stated that staff “ it is impossible to keep up with the incontinence care needs of residents because staff must sign out one or two packs of wipes per shift, and they cannot adequately clean each resident with this limited number of wipes, given the diarrhea outbreak." During the tour of the facility and the room attached to the ED office, LPA observed 18 boxes of wipes and gloves of different size with other cleaning items. Continues on LIC 9099C page 3 Page 3. LPA interviewed memory care director about hygiene items shortages, she stated that previously staff taking a box of hygiene items per day to meet the resident's needs, but items allegedly being stolen by staff and they were taking to their home, so Wipes and Goves Check Out Log is created to prevent the misuse of the items. During an interview with memory care director, she stated that they can pick as much as wipes if needed but it should be logged in log sheet. LPA reviewed the log and observed that the log sheet is created effective 6/16/ 2026. Allegation: Staff are not preventing roach infestation in the facility During the tour of memory care hallways, three laundry rooms, dining room and pantry attached to the dining room, 6 out of 12 bedrooms shower, LPAs observed no roaches. Facility observed to be clean and sanitary. LPAs reviewed Pest Control Service Reports for the month of June and observed that California Pest Control came to the facility and provided service on the following dates: 6/24/2026, 6/17/2026, 6/10/2026. On 5/22/2026, the same allegation (Facility staff does not ensure facility is free of pests) was investigated by LPA Christina Valerio. LPA Valerio requested and obtained Pest Control Service Reports for March 2026 and April 2026. According to the licensee, the facility has a contract with California Pest Control and they come out weekly. LPA Valerio observed California Pest Control came to the facility to provide services on the following dates: 03/03/2026, 03/10/2025,03/17/2026, 03/20/2026, 03/24/2026, 03/31/2026, 04/07/2026, 04/14/2026, 04/21/2026 Allegation: Licensee is not ensuring adequate staffing to meet residents' needs During an interview with Memory Care director Shreetika, she stated that currently there are two med tech and 6 caregivers for both memory care and assisted living wings in which one of the memory care caregivers comes from Clipboard, whenever needed. Shreetika checked that system and LPA observed that 4 caregivers from clipboard were on duty for today 6/26/2026. Based on the observation, record review and interview with residents and staff, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held and a copy of report was provided to facility.the state’s words, verbatim · CDSS document, Jun 26, 2026 · control 27-AS-20260625141905

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Resident sustained injuries due to staff neglect or physical abuse

On 6/26/2026, Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to deliver findings for this complaint investigation. LPA met with Administrator and explained the purpose of the visit. Allegation: Resident sustained injuries due to staff neglect or physical abuse On 1/22/26 LPA interviewed the ED. It was stated that R1 was sent out to Kaiser for a swollen hand. R2 stated this had happened before to R1 and they had to cut her ring off. According to S2, NOC shift never noticed swollen hand. R1 has history of falls but due to cognitive impairment they are unable to state whether the swollen hand was due to a fall or not. Based on Interviews and record review, the above allegation is 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 was conducted with the licensee. Appeal Rights were issued, and a copy of this report was left at the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 26, 2026 · control 27-AS-20260115114001

Allegation investigated: Staff did not administer resident's medication as prescribed. Staff mismanages resident's medication.

On 6/26/2026, Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to deliver findings for this complaint investigation. LPA met with Administrator and explained the purpose of the visit. Allegation: Staff did not administer resident's medication as prescribed. On 1/14/26 LPA Viarella reviewed the following medication logs for R1. R1 was prescribed PRN Stomach Relief 262mg/15ml oral suspension to be taken 30ml by mouth every hour as needed for stomach upset. Facility did not have it available during this review. Facility has on hand a Geri Lanta 400mg (RX2613946270) for upset stomach. This medication is not listed in MAR nor in the prescription list dated 12/29/25. R1 also showed a PRN for the Calcium Carbonate 200mg chew tab to be taken 2 to 4 tablets by mouth as needed for acid reflux, this medication is not listed in MAR. Per interview with med tech on duty, it was stated that R1 has not taken this in a while but cannot confirm if there is a discontinue order from the doctor. For the PRN Benzonatate 100mg capsule to be taken 1 cap by mouth every 6 hours as needed for cough, this medication was not available during this visit; med tech is unable to confirm if it was discontinued. Based on record reviewrd, the above allegation is substantiated. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the above is SUBSTANTIATED. Substantiated Allegation: Staff mismanages resident's medication. On 12/18/25 LPA Viarella asked the ED to define what his understanding of a medication error was. ED replied to the following: wrong dose, wrong resident, wrong time (not in the window, an hour before or after the prescribed time) or if was supposed to be given every 6 hours and we gave it every 8 and no order is on file for the medication. LPA requested files for Residents R1 - R8. The ED told LPAs that they did not have proper PRN release form on file for every resident. ED told LPAs that they do have documentation for all the shadowing required for med techs. Based on record review and interview with ED the above allegation is substantiated. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the above is SUBSTANTIATED. The following deficiency, 87465(e) (1-4) is cited per California Code of Regulations, TITLE 22, DIVISION 6, CHAPTER 8 Article 8. This is a repeat violation and needs a civil penalty assessed. Exit interview was conducted with the licensee. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jun 26, 2026 · control 27-AS-20260109133945

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e)(1-4) · Plan of correction due date: Jun 29, 2026

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.(1) The specific symptoms which indicate the need for the use of the medication.(2)The exact dosage.(3) The minimum number of hours between doses.(4) the maximum number of doses allowed in each 24-hour period. This requirement was not met as evidenced by med pass observations and records reviewed. medication were not recorded as required and not given as orderedthe state’s words, verbatim · CDSS document, Jun 26, 2026

Plan of correction: Med-tech in-service training will be conducted on the POC date if additional time is need the facility will send an email to the LPA to request additional time.

Allegation investigated: Staff allow residents to be left in soiled clothing for extended periods of time.

On 6/26/2026, Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to deliver findings for this complaint investigation. LPA met with Administrator and explained the purpose of the visit. Allegation: Staff allow residents to be left in soiled clothing for extended periods of time. On two separate visits to the facility the call logs were reviewed and the longest response time to a call button from a resident was 12 minutes. Based on observations and records review the allegation cannot be substantiated. 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. Unsubstantiated The following deficiency, 87465(e) (1-4) is cited per California Code of Regulations, TITLE 22, DIVISION 6, CHAPTER 8 Article 8. Exit interview was conducted with the licensee. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jun 26, 2026 · control 27-AS-20251208114720

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e)(1-4) · Plan of correction due date: Jun 29, 2026

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.(1) The specific symptoms which indicate the need for the use of the medication.(2)The exact dosage.(3) The minimum number of hours between doses.(4) the maximum number of doses allowed in each 24-hour period. This requirement was not met as evidenced by med pass observations were made at 12:24pm. Review of resident file showed that R1 was prescribed a PRN to be taken every hour and it was not available. Other inconsistencies were noted and the medtech was unable to provide an explanation. This is an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Jun 26, 2026

Plan of correction: Med-tech in-service training will be conducted on the POC date if additional time is need the facility will send an email to the LPA to request additional time.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christina Valerio and LPA Reza Jamaly arrived unannounced to conduct a complaint investigation. During the subsequent visit, LPAs were informed by Administrator Donnabell Galicia of two incidents involving staff and resident and one incident involving a resident and outside person. Incident 1 - Alleged financial abuse - Administrator Donnabell learned that Resident 1 (R1) allegedly gave Staff 1 (S1) money. According to Administrator Donnabell, the facility is currently conducting an internal investigation. Based on an interview conducted by management, S1 denies the allegation of receiving money from R1. Incident 2 - Alleged financial abuse - Administrator Donnabell reported that on June 26, 2026, Resident 2 (R2) responsible party (RP) informed Staff 2 (S2) that R2 has been sending money to Staff 3 (S3), Staff 4(S4), and another resident. R2's RP knows this has happened because of screen shots taken from R2's phone. S2 reported the incident to Administrator Donnabell on June 26, 2026. S3 is a currently employee and S4 is a previous employee that no longer works for the facility. Incident 3 - Alleged financial abuse - Administrator Donnabell reported to LPA that Resident 3 (R3) was a victim to having a money withdrawal from a taxi driver. According to Administrator Donnabell, the facility will be sending incident reports and SOC 341 to all necessary agencies, including Community Care Licensing (CCL), by close of business on June 26, 2026. LPA Valerio to receive supporting information for Incident 1, copies of screen shot for Incident 2, names of staff for Incident 1 and Incident 2, and copies of incident reports for incident 1, 2, and 3. No deficiencies were cited during today's visit. An exit interview was held, and a copy of this report was provided to Administrator Donnabell Galicia.the state’s words, verbatim · CDSS document, Jun 26, 2026

Type of visit: Case Management - Deficiencies

On 06/25/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility conduct a case management visit following an observation made during a tour of the facility. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Executive Director (ED) Donnabell Galacia. The two met and a brief interviewed followed. During her walkthrough today, LPA observed an exit door that was off its hinges and propped into the door frame. LPA took a photo for documentation purposes. The resident (R1) with this LPA at the time said that they went to exit the building one day and the door just felll out if its frame. R1 stated that they were amazed that the glass did not shatter. This deficiency was cited on the LIC 809D page. According to the California Code of Regulations, Title 22, not other deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was provided along with APPEAL RIGHTS.the state’s words, verbatim · CDSS document, Jun 25, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jun 25, 2026

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. The above regulation was not met as evidenced by: LPA observed the exit door propped into the door frame. This posed an immediate threat to the health safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jun 25, 2026

Plan of correction: The Executive Director had this door fixed prior to this LPA leaving the building today. LPA tested the door and it opened and closed properly. This POC has been cleared.

Allegation investigated: Facility staff does not ensure facility is free of pests Facility staff does not answer phone calls

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a complaint investigation visit. LPA Valerio met with Memory Care Director (MCD) Shreetika Chand, and explained the purpose of the visit. Allegation: Facility staff does not ensure facility is free of pests According to the Reporting Party (RP), the RP stated there were roaches in the staff break room and laundry room during or around March of 2026. On 05/28/2026, LPA Valerio observed the staff break room and laundry room. LPA Valerio did not observe any pest in staff break room or the laundry room. Continues on LIC 9099 - C... Unsubstantiated Continued from LIC 9099 Allegation: Facility staff does not ensure facility is free of pests LPA Valerio was requested and obtained Pest Control Service Reports for March 2026 and April 2026. According to the licensee, the facility has a contract with California Pest Control and they come out weekly. LPA Valerio observed California Pest Control came to the facility to provide services on the following dates: 03/03/2026 03/10/2025 03/17/2026 03/20/2026 03/24/2026 03/31/2026 04/07/2026 04/14/2026 04/21/2026 04/28/2026 Allegation: Facility staff does not answer phone calls According to the Reporting Party (RP), they attempted to call the facility at (916) 482-7745 but the voicemail box was full and unable to take messages. On 05/26/2026, LPA Valerio contacted the facility number, 916-482-7745. The phone rang three times and was answered by facility staff. On 05/28/2026, LPA Valerio called the facility number, 916-482-7745, which was answered by facility staff after two rings. LPA Valerio observed front desk staff answering the phone during the visit on 05/28/2026. Based on all the information collected by the Department, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, May 28, 2026 · control 27-AS-20260522104217

Allegation investigated: Staff fail to answer call lights timely

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a complaint investigation. LPA Valerio met with Administrator Donnabell Galicia, and explained the purpose of the visit. On 05/21/2026, LPA Valerio observed call lights were answered timely. The highest time in the last 24 hours was 12 minutes. On 05/22/2026, LPA Valerio observed call lights were not answered timely before LPAs arrival. There were varying time frames such as 18, 24, 82, 12, and 42 minutes. According to staff interviews, sometimes it is forgotten to clear the light or the call pendant is missing. LPA Valerio reviewed a Resident Council Meeting notes date May 7, 2026. Continues on LIC 9099- C... Substantiated Continued from LIC 9099 According to the Resident Council Meeting Notes, residents expressed concerns with call lights being answered timely. They specifically stated that response time to residents rooms is too slow, insufficient staffing levels at night, residents are not informed when new staff will be entering their rooms, and memory care staff observed sleeping, on phones, sitting idle during shifts According to the posted Response from management to the resident council meeting, management responded with the following: "Management has address response time expectation with staff. Ongoing communication, monitoring, and training are being conducted to improve response times. Staff have been instructed to monitoring call systems and call logs more frequently to improve responsiveness and resident assistance. Management has addressed these concerns directly with staff members. Resident are encouraged to continue reporting concerns to management so they can be addressed promptly." Based on interviews, records review and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the facility. 05/21/2026: LPA Valerio observed housekeeping cleaning AL rooms 05/22/2026 LPA Valerio observed housekeeping cleaning - LPA Valerio saw 3 housekeeping; 2 in AL and 1 in MC. LPA observed and spoke to the person collecting the trash. Staff stated they come by every day to pick up the trash. There are only a few residents that say do not come to pick it up. Staff stated that residents can refuse trash pick or for staff to enter their room. LPA Valerio observed the rooms that have posted signs stating when they preferred trash pick up. Based on this information, the allegation is unfounded. A finding of unfounded means the allegation is false, could not have happened, or is without a reasonable basis. Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited. An exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 22, 2026 · control 27-AS-20260218102101

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jun 22, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, ... (4) To care, supervision, and services that meet their individual needs ... This requirement was not met as evidenced by: Based on observation, records review, and interviews, the licensee did not ensure staff answered call lights in a timely manner, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2026

Plan of correction: Licensee stated they will provide LPA Valerio a in-service training sign in sheet along with training materials and plan to hire additional staff by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management visit. LPA Valerio met with Administrator Donnabell Galicia, and explained the purpose of the visit. LPA Valerio toured the facility to ensure compliance with Title 22 regulations. LPA Valerio observed all doors leading into the middle courtyard to be open, which allows hot air to come into the facility. LPA Valerio closed all the doors due to the facility warming up while the air conditioning was on. According to administrator Donnabell, they are advising all staff to close the doors if they see it open. The facility testing a new system to determine if it helps the situation. The new system would be installing automatic mechanisms on all the doors in order for the doors to automatically close if it is opened. Currently, they have it installed on one door. LPA Valerio observed thermostat monitors missing in the memory care area. LPA Valerio observed two (2) swamp coolers and two (2) fans. The thermostat located in the MC hallway was set to 68 degrees, but the temperature showed a reading of 74 degrees. LPA Valerio checked the thermostat in the kitchen/dinning hall and the thermostat showed 78 degrees at 1:49 PM. At 2:55 PM, the thermostat read 80 degrees F. LPA Valerio observed one a/c unit set to 67 degree and three fans in the dinning hall. In the kitchen area where staff prepare meals, there were two fans. At 4:24PM, the thermostat read a temperature of 83 degrees. However, LPA Valerio used state issued room thermometer which stated the temperature inside the dinning hall was 77 to 80 degrees F depending on where LPA and Administrator was standing. Continues on LIC 809- C... Continued from LIC 809 It was reported that the dinning hall was too hot during dinner time on 05/21/2026; therefore, residents were directed not to eat there and eat in their room or other areas of the facility. The thermostat read at 83 degrees. According to resident interviews, residents expressed that the dinning hall was hot and the rooms are hot, so they would rather eat in the dinning hall. It was reported to LPA Valerio on 05/21/2026 that staff do not have wipes to use to change residents and a watered pad are used instead. On 05/21/2026, LPA Valerio observed a staff grabbing wipes from the management office. On 05/22/2026, LPA Valerio observed two (2) boxes of nine (9) pack of wipes located in the management office. LPA Valerio observed one pack of wipes located in the back business office, which is also locked with a code. According to Administrator Donnabell, management staff provide a couple pack of wipes to staff upon request. If they need additional packs, they can ask management. LPA Valerio provided a Technical Violation to ensure staff are made aware of the process and a plan is put in place to have wipe packs accessible when management if not present in the facility. Per California Code of Regulations (CCR) - Title 22 - a technical violation and a citation was issued during today's visit. Appeal rights provided. Failure to correct deficiencies may result in civil penalties. An exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 22, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(b) · Plan of correction due date: May 23, 2026

87303 Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. This requirement was not met as evidenced by: Based on observations and interviews, the licensee did not ensure the air conditioning and temporary cooling systems provided a comfortable temperature for residents in care, which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2026

Plan of correction: Licensee stated they have ordered filters for the HVAC system and are waiting for them to come in. LPA Valerio to receive notification from Licensee Shelly Cha regarding her plan to address the air conditioning by POC due date of 05/23/2026.

Allegation investigated: Questionable death

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA Valerio met with Administrator Donnabell Galicia, and explained the purpose of the visit. The investigation consisted of record reviews of Resident 1’s (R1) death certificate, R1 Death report and medical assessment records. The Department reviewed the Death Report of R1, dated on 3/5/2026, which says" R1 had numerous medical diagnoses, related to the cancer, such as monoclonal gammopathy, basal cell carcinoma, and Lymphocytosis". Continues on LIC 9099- C... Unsubstantiated Continued from LIC 9099 The department reviewed R1's Medical Assessment, which states" R1 is diagnosed with severe protein-calorie malnutrition, NSTEMI (non-ST-elevation myocardial infarction), CHF (congestive heart failure), schizophrenia in remission, orthostatic hypotension, tardive dyskinesia, dysphagia, and HLD (hyperlipidemia). R1 takes medication and requires assistance with medication management. R1 uses a walker and wheelchair due to motor impairment/paralysis and has a history of skin condition breakdown…". Additionally, department reviewed R1 Death Certificate, which states " R1 immediate cause of death is listed as non-ST-segment elevation myocardial infarction, with a time interval between the onset and death noted in days. The underlying conditions contributing to R1 death are anemia, with the time interval between the onset and death noted in months, and coronary artery disease, with the time interval between the onset and death noted in years. Other significant conditions contributing to R1 death, but not resulting in the underlying cause, are chronic lymphocytic leukemia". Due to above note information, the Department concluded the following: “Resident 1’s (R1) death certificate states [R1] immediate cause of death as non-ST-segment elevation myocardial infarction, with the time interval between the onset and date noted in days. There are no indications that R1’s death was questionable.” Based on all the information collected by the Department, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, May 21, 2026 · control 27-AS-20260305151149

Allegation investigated: Staff spoke inappropriately to a resident Staff served a poor quality of food to a resident

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a complaint investigation and deliver findings. LPA Valerio me with Administrator Donnabell Galicia, and explained the purpose of the visit. Allegation: Staff spoke inappropriately to a resident LPA Valerio interviewed Staff 1 (S1). S1 stated S1 never yelled at Resident 1 (R1), and that "it was actually the other way around." S1 said R1 came into S1 office and was discussing R1's food preference. R1 started raising their voice and S1 stated they would discuss at a later time. R1 then attempted to hit S1. Police was contacted but nothing else happened after that. Continues on LIC 9099 - C.. Unsubstantiated Continued from LIC 9099 LPA Valerio interviewed R1. R1 stated there are some staff with a tone, but R1 avoids the one R1 does not like. R1 does not recall if any staff have yelled at R1. Allegation: Staff served a poor quality of food to a resident LPA Valerio interviewed R1. R1 does not recall any complaints regarding the food. R1 enjoys the food and would know if R1 had moldy food. LPA Valerio interviewed Resident 2 (R2), Resident 3 (R3), Resident 4 (R4), and Resident 5 (R). Residents did not have any complaints regarding the food quality. Residents expressed that food is the best and they look forward to the meals. LPA Valerio obtained pictures of the food provided on different dates. The pictures were taken by kitchen staff. LPA Valerio observed the following food: Chow mein with julienne carrot, mushrooms, broccoli, onions, green beans, and beef served with a bread roll and egg roll, Grilled chicken breast with fettuccine noodles, white cream sauce served with a garden salad mixed with greens, bell peppers, cherry tomato, and green onions, Ground beef with a mix bean and vegetable salad, breakfast oats served with bacon, sausage, and fresh fruit, bacon wrapped meat loaf served with a cinnamon roll, steamed vegetables, and potato casserole. Based on all the information collected by the Department, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred, therefore the allegations are UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, May 21, 2026 · control 27-AS-20260218090557

Allegation investigated: Licensee does not ensure that residents care plans are being followed

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to deliver complaint findings. LPA Valerio met with Administrator Donnabell Galicia, and explained the purpose of the visit. The department reviewed facility records for Resident 1 (R1). Per facility records, R1 is not able to administer R1 own medications. However, based on four (4) staff interviews, staff stated that R1 is allowed to pick up prescription medication from an outside pharmacy and at times held onto and self-administered these medications on multiple occasions. Continues on LIC 9099 - C... Substantiated Continued from LIC 9099 An interview with staff revealed that the facility did not have a plan in place to address R1’s substance abuse despite R1 having a history of drug abuse and being suspected of possessing drugs on two separate occasions. However, efforts were continuously made in conjunction with R1s Care Coordination Agency to find another facility better suited for R1, without success. According to an interview with staff, staff reported that they felt if management had not been checking on staff, staff would not follow resident's care plan. Based on interviews and records review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the facility. Continued from LIC 9099 - A According to the Sacramento County Sheriff's Office (SCSO) Report, the responding officer was unable to identify the white crystal-like substance. The officer noted that there were no other paraphernalia or substances found in the room; and that facility staff also had access to R1's room. R1 was not present for questioning by the responding officer. The substance was never tested or identified prior to destruction. The department attempted to interview R1; however, R1 refused to provide a statement. According to staff interviews, staff suspected the white powder, found in R1's room, in a prescription bottle of Trazadone issued to R1 was an illegal substance but were unsure. Staff denied that R1 exhibited signs of being under the influence at any time. According to interviews with residents, residents did not report being aware of any illegal substance being present in the community or being used in the community. Allegation: Unqualified staff are providing nursing care to residents while in care. According to Staff 1 (S1), S1 reported having training prior to working on the floor. S1 completed online training over four days and another four days of shadowing staff as they performed caregiver duties. According to an interview with Staff 2 (S2), S2 reported received six day of training in total including online and shadowing their duties. S2 was hired to be behavioral specialist but has been scheduled as a caregiver. According to an interview with Staff 3 (S3), S3 stated Medication Technicians need to complete 16-20 hours on Relias and then two days of shadowing. S3 reported that a staff member can only be a Medication Technician if they have been trained. A caregiver who does not have medication training cannot pass medications. According to an interview with Staff 4 (S4), S4 is able to be a medication technician and a caregiver because S4 has been trained to do both. According to an interview with a resident, a resident reported that past medication technicians have expressed that they do not know their job. New medication technicians are allegedly teaching other new staff. This resident would not disclose names of the staff. Continues on LIC 9099-C, Page 3... Continued from LIC 9099- C, Page 2 According to an interview with Staff 5 (S5), there was a new employee put on the floor; however, when they were put on the floor, they were not alone and with another staff member. Allegation: Staff are being instructed to make false claims to CCLD. According to interviews with staff, four (4) out of four (4) interviews reported that management does not instruct staff to make false claims or hide information. According to interview with Resident 2 (R2), R2 stated staff encourage residents to voice their complaints so issues can be addressed. R2 reported that the facility has a Town Hall Meeting to report complaints to staff. Based on all the information collected by the Department, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred, therefore the allegations are UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, May 21, 2026 · control 27-AS-20260224160732

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: May 22, 2026

87465 Incidental Medical and Dental Care (a) A plan...shall be developed by each facility… (1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on records review and staff interviews, the licensee did not ensure to put a plan in place to pick up R1's medications, which posed an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: Licensee stated the facility attempted to find proper placement for R1 and attempted to update LIC 602 - Physician report to reflect current information. Licensee will send plan to address R1 picking up own medication and update LIC 602 by POC due date.

Type of visit: Case Management - Deficiencies

On 05/15/26, Licensing Program Analyst, (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit related to complaint investigation number 27-AS-20250522140000. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator/Executive Director (ED). LPA met with Shreetika Chand Memory Care Director (MCD) and Regional Service Director (RSD) and this LPA reviewed the citations to be delivered today as a result of the above mentioned investigation. A tour was also conducted during this visit. Through the course of the investigation into the death of a resident (R1), this LPA learned that the required 2 hour checks for 05/03/25 were not conducted as required. This deficiency has been cited on the LIC 809D page. LPA reviewed R1s care plans dated 07/12/24, 8/27/24, 10/11/24, 11/08/24, and 03/05/25. The first 4 care plans all state that R1 required 2 hour checks and was a fall risk, yet even after having falls as documented by incident reports, no changes were made to R1's care plan. There was a slight change to the care plan on 03/05/25 when it was noted on page 3 that R1, "returned from hospital visit from VA with seizure activity and a change in ambulation and locomotion," yet no changes were made to R1's care plan to address R1's propensity to fall. This deficiency has been cited on the LIC 809D page. LPA reviewed incident reports for R1. In them, the facility reports that they ran out of R1’s medications. On 10/18/24 R1 was not administered the following: "cranberry juice cap 425 mg (1&2), Finasteride (10/02/24, 10/11/24, 10/21/24) Flovent 120 mcg/inh (10/23/24 - 10/25/24), Fluticasone (10/15/24 -10/22/24) Folic Acid 1 mg (10/01/24 – 10/11/24) Lamotrigine 200mg (10/02/24, 10/11/24 -10/15/24), Propranolol 80 mg (10/07/24,10/11/24, 10/18/24), Tamsulosin 0.4mg (10/10/24 – 10/15/24), Thera vite max (25) Vitamin b12 500 mg (10/10-/24-10/14/24) for October." On 08/02/24, R1 was sent out for emergency medication refills. On 03/17/25 R1 the facility reported that the resident was not administered Acetaminophen that they were prescribed to take 3X daily. All doses were missed on 3/16/25 and 3/27/25 because their medication was out of stock. On 05/03/25, R1 was not administered their morning dose of Lamotrigine Oral Tablet 150 MG because the facility did not ensure that they had a refill on hand . This deficiency has been cited on the LIC 809D page. According to the California Code of Regulations Title 22, no other deficiencies were observed or cited during today's visit. A copy of this report was provided and an exit interview was conducted with Chand.the state’s words, verbatim · CDSS document, May 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: May 16, 2026

Basic Services shall at a minimum include: Care and supervision as defined in Section 87101(c )(3) and Health and Safety Code section 1569.2(c ) The above Requirement was not met as evidenced by: Based on interviews and a review of records, staff did not conduct 2 hour checks which were outlined in R1's care plan. This posed an immediate threat to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, May 15, 2026

Plan of correction: The Memory Care Director and Regional Service Coordinator stated they will create a safety check list which will require both staff and management signatures to ensure that all checks are competed as required per care plans. These will be submitted to CCL by the COB 05/16/26.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87463(g) · Plan of correction due date: May 16, 2026

Reappraisals (g) The licensee shall ensure corresponding changes are made in the care and supervision provided to the resident. The above requirement was not met as evidenced by: Based on a review of records, reappraisals did not include a change in the care plan to meet the needs of R1.the state’s words, verbatim · CDSS document, May 15, 2026

Plan of correction: The Memory Care Director and Regional Service Coordinator stated that they will conduct an audit of all resident files to see which require updated LIC 602s and/or careplans for MC and AL. The Audit for MC will be due by COB 05/16/26. AL will be due

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

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility.... shall encourage routine medical & dental care & provide for assistance in obtaining such care... This requirement was not met as evidenced by: The above regulation was not met as evidenced by the document review showing that the facility ran out of R1's prescriptions on more than 12 occasions involving 12 different prescriptions.the state’s words, verbatim · CDSS document, May 15, 2026

Plan of correction: The Memory Care Director and Regional Service Coordinator stated they have begun retraining all medication technicians and are assigning a # of residents to each medtech so that they will be responsible for ordering their meds. A written update with a plan of completion will be submitted to CCL by COB.

Allegation investigated: Staff do not distribute residents' medications as prescribed. Staff do not respond to residents' care needs in a timely manner. Staff do not assist resident with showering.

On 05/13/26, Licensing Program Analyst (LPA) Kimberly Viarella and Regional Manager (RM) Stephenie Doub, made an unannounced visit to this facility to deliver the findings for the above complaint. LPA/RM identified themselves upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator/Executive Director (ED) Donnabell Galicia. LPA/RM met with the Memory Care Director, Tika Chand who escorted the pair to the model room to work. The LPA/RM conducted an audit of open complaints, and then toured the facility. Regarding the allegation: Staff do not distribute residents' medications as prescribed. This allegation was previously substantiated in complaint # 27-AS 20250910090018 therefore a deficiency is not being issued for this allegation. Regarding the allegation: Staff do not respond to residents' care needs in a timely manner. This allegation was previously substantiated in complaint # 27-AS 20250910090018 therefore a deficiency Substantiated is not being issued for this allegation. Regarding the allegation: Staff do not assist residents with showering. Based on an interview with Ashley Sylve, Designee and Regional Quality Assurance Director, 4 staff (S1-S4) received disciplinary warning notices for "failure to follow company policies and procedures." Sylve stated that she wanted to ensure that residents were getting their showers, and if they refused, that it was documented appropriately as required. The standard for the preponderance of evidence has been met, the department finds the above allegation SUBSTANTIATED. This deficiency was cited on the LIC 9099D page. According to the California Code of Regulations, Title 22 there were no other deficiencies cited during this visit. A copy of this report was provided along with APPEAL RIGHTS and an exited interview was conducted with Galicia. substituted for linens. The standard for the preponderance of evidence was not met. The department found the allegation "Staff do not provide residents with linen," UNSUBSTANTIATED. A finding of Unsubstantiated means that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Regarding: Staff do not assist resident with obtaining medical care. R5 was a resident receiving hospice services. Care notes on 10/01/25, 10/02/25, 10/05/25, 10/10/25 noted the swelling and discoloration of R5's toe. An antibiotic arrived on 10/07 and instructions that hospice nurses would treat the infected area twice a week. The hospice nurse was contacted on each of the above dates to come and evaluate R5. The hospice nurse, a medical professional, did not deem it necessary to send R5 to the hospital for evaluation. On 10/10/25, hospice was notified that the toe itself "was not completely attached" and a nurse came out to evaluate the resident. On 10/13/25 R5 "was transported to the hospital due to the discoloration of their toe which appeared to be black." R5 returned on 10/13/25 with no new orders or services. The standard for the preponderance of evidence was not met. The facility did contact the appropriate medical professional in a timely fashion. The department found the above allegation UNSUBSTANTIATED. A finding of Unsubstantiated means that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit. A copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted.the state’s words, verbatim · CDSS document, May 13, 2026 · control 27-AS-20251013083053

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.2(c) · Plan of correction due date: Jun 1, 2026

(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living.... or personal care. This requirememt was not met as evidenced by: Based on a review of records, 4/4 staff were not following company policies regarding showers. This posed a potential threat the health. safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, May 13, 2026

Plan of correction: ED stated they created a new shower schedule and will be rotating staff to ensure that all staff are appropriately trained. ED will provide shower schedule and training documents signed by those who have completed it by the close of business on June 1, 2026.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Viarella and Regional Manager (RM) Stephenie Doub made an unannounced visit to the facility on this day for the purpose of conducting a case management visit. LPA and RM met with Memory Care Director (MCD) Tika Chand and explained the reason for the visit. At approximately 11:40 AM, LPA and RM conducted a walk through the facility. LPA and RM entered the memory care area and observed residents eating lunch. There was one staff present in the dining room with sixteen residents. Upon entering the dining area, LPA and RM observed a resident requesting more juice to drink. Staff advised the resident that there was only enough juice for each resident to have one cup and only water was available, if they wanted an additional something to drink. RM Doub observed one resident not eating their food. The resident stated that they did not want the food and wanted a grilled cheese sandwich. RM Doub asked the staff present if there was a way for the resident to get something else to eat. The staff reported that they would need to wait until another staff member was present. It was approximately 20 minutes before another caregiver arrived. LPA followed up with dining services who reported that there was no request for any meal substitutions for memory care. LPA observed the bathroom faucet in RM 34 was not working. The resident who resides in that room stated that the faucet had not been working since they moved in two weeks ago. LPA and RM also observed the drawer in RM 30 to be off the hinge preventing the drawer from being able to open or close. At approximately 12:20 LPA and RM observed residents sitting in the courtyard smoking just outside of the building. Based on the information above the following deficiencies were cited per Title 22 regulations. An exit interview was conducted with and a copy of this report along with appeal rights was provided.the state’s words, verbatim · CDSS document, May 13, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 14, 2026

87468.2 Add. Per. Rights of Res.in Privately Op. Facilities (a)(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers... This requirement was not met as evidenced by" Based on LPA observations, staff were unable to meet the residents’ request for additional drinks and meal substitutions because there was only one staff present to 16 residents during meal service. This poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, May 13, 2026

Plan of correction: ED will review the schedule to ensure coverage. No activites or showers during meal periods. ED will submit schedule of memory care staff and med techs for a 4 week period by close of business 05/14/26.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1(a) · Plan of correction due date: May 14, 2026

Personal Rights of Residents in All Facilities (a) ...shall have all of the...personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. The above requirement was not met as evidenced by: Based on observation staff were allowing residents to smoke in the courtyard which is not the designated smoking area. This poses an immediate risk to health and safety of residents in care.the state’s words, verbatim · CDSS document, May 13, 2026

Plan of correction: ED will add more no smoking signs and signs to direct residents to direct resdients to the designated smoking area. Pictures will be sent to CCL by the close of business 5/14/26.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 27, 2026

Maintenance and Operation 87303(a) The facility shall be clean, safe, sanitary and in good repair at all times.... This requirement was not met as evidenced by: Based on observation resident faucet and drawer were not in working order. This poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, May 13, 2026

Plan of correction: ED will have repairs made by 05/27/26. ED will send video footage of the repaired items working properly by 05/27/26.

Allegation investigated: Staff are mismanaging resident's medications Facility is in financial distress Staff inappropriately moved residents to other rooms for staff use of those rooms

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a complaint investigation and deliver complaint findings. LPA Valerio met with Administrator Donnabell, and explained the purpose of the visit. The following has been determined as it relates to the following allegations: Allegation: Staff are mismanaging resident's medications LPA Valerio requested three (3) resident files from previous interim administrator Rosalie Sullivan. LPA Valerio received and reviewed Medication Administration Records for Resident 1 (R1), Resident 2 (R2), and Resident 3 (R3). R1 did not receive a medication on October 29, 2025. Continues on LIC 9099 - C... Substantiated Continued from LIC 9099 There were no notes on the MAR to indicate the reason for the missed medication dose on the records provided to LPA Valerio. On October 1, 2025, R2 did not receive their dose of "Flucticasone Prop spray" due to the medication not being available in the community." R3 had an order for Alendronate sodium. The order is to take 1 Tab by mouth every week. According to the MAR, facility staff indicated that the medication was not available on October 23, 2025 and October 30, 2025. R3 also had an order for Vitamin D3, which was not given on October 5, 2025 because the facility did not have it available. On April 30, 2026, LPA Valerio received an Unusual Incident Report (UIR) for Resident 4 (R4). According to the UIR, R4 was provided a medication that was for another resident; however, the medication was not fully ingested. R4 was sent out and returned to the community the same day with a discharge diagnosis of "worried well". Allegation: Facility is in financial distress The solvency audit was conducted by Audit Investigator Banahene. According to the The September 2025 sample month Profit & Loss statement, the facility did not generate any revenues and had a net loss. The licensee did not provide any document to show that the facility’s rent or mortgage was paid and that the licensee has good control over the facility. The review of the six-month utility billings showed that the licensee made full payments for PG&E, Comcast, Waste Management, Pest Control, Consolidated Utilities. However, the licensee did not make any payment for SMUD in April 2025 and made only partial payments in May, August, September 2025 and carried unpaid balance as high as $25,708. Additionally, the records show that the licensee had a lot of significant monthly financial obligations (loans and credits cards), which creates some financial concern due to the facility not generating income or sufficient income to cover expenses. Additionally, a working capital analysis was performed and the licensee had a negative working capital for the Sample Month September 2025. A negative working capital indicates that the company doesn’t have enough current assets to cover its short-term obligations and may have trouble paying suppliers and creditors and difficulty raising fund. The bank statements provided showed positive balances, however, the positive balances were significantly below the estimated monthly expenses for the facility with 160 beds. Moreover, it appears the licensee does not have sufficient cash reserves to cover the operating cost. Continues on LIC 9099 - C... Allegation: Staff inappropriately moved residents to other rooms for staff use of those rooms On 02/03/2026, LPA Valerio was told by previous Administrator Johnathan Aguilar that as far as he knew, the residents should have been informed. All residents were moved due to renovations and maintenance and would be moved back after it was done. On 02/03/2026 , Staff 1 (S1) informed LPA Valerio that residents were given notice. S1 remembers the paper and an email that was sent from management. LPA did not receive a copy of the notice that was provided to the residents. LPA Valerio reviewed resident council meeting notes dated October 2,2025. Resident Council Meeting notes are written by the residents and submitted the executive director for review. According to the meeting notes, residents wrote the following: "Confusion reigns! Everyone is confused about the abrupt changes with NO notification. Some people woke up on Monday being told they were moving that day. People were thrown together with no consideration about compatibility. We are repeatedly told that you work for us, but this is a prime example of that not being true. What is going on? Residents are upset over the way the changes were handled so abruptly without notification. Management says they posted flyers; but they were posted after the moving had begun; people don't go down the halls reading what's on the walls. It would have been better had they given notices to each resident effected. Prior to the flyers being posted, people were just moved to different areas without notice. It was upsetting." According to an interview with Resident 4 (R4), the previous management were moving people abruptly without notice. They posted it on the wall but we don’t look at wall. They said the room was a problem but they never did the work. Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, May 12, 2026 · control 27-AS-20250925104337

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 13, 2026

87465 Incidental Medical and Dental Care (a).…(4)The licensee shall assist residents with self administered medications as needed…This requirement was not met as evidenced by: Based on record reviewed, the facility did not ensure that R1, R2, R3, and R4 was assisted with receiving their medications, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Licensee stated the Regional Nurse, Carolyn, will be retraining the staff on all Medication related topics effective 05/12/2026. LPA Valerio to receive by the POC due date the in-service training provided today and what topics will be covered in the upcoming weeks.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(3) · Plan of correction due date: May 13, 2026

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7).... (3) Ability to maintain or supervise the maintenance of financial and other records. This requirement was not met as evidenced by: Based on the solvency audit, the licensee did not ensure to maintain or supervise the maintenance of financial or other records, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Licensee stated they have implemented weekly financial reviews (Rent, Staff, Budget) with the Administrator. LPA Valerio to receive a copy of their standard operating procedure by POC due date,

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87205 · Plan of correction due date: May 13, 2026

87205 Accountability of Licensee Governing Body (b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. This requirement was not met as evidenced by: Based on records review and interviews, the licensee did not take accountability for past due balances for the facility, which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Licensee stated they have implemented checklists that will be submitted to the Licensee moving forward, which according to the licensee, allows them to be more involved and aware of daily operations. LPA Valerio to receive a copy of policy and procedure by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: May 13, 2026

87213 Finances Finance The licensee shall have a financial plan.. and that assures sufficient resources to meet operating costs for care of residents... This requirement was not met as evidenced by: Based on records review, the licensee did not have sufficient cash resources to cover operating cost, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Licensee stated they are working on building an emergency fund by reviewing resident rental cost/care program. LPA Valerio to receive a statement from Licensee Shelly by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(16) · Plan of correction due date: May 13, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a)..:(16)To written notice of any room changes at least 30 days in advance unless a room change is agreed to by the resident... this requirement was not met as evidenced by: Based on record reviews and interviews, the licensee did not ensure to give proper notice to the resident prior to moving residents to a different room, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Licensee stated the facility will ensure that if there are any resident room change, the facility will ensure a face to face meeting will occur, have a resident sign off on the notice, and ensure the resident has enough notice. LPA Valerio to receive a copy of policy and procedure by POC due date.

Allegation investigated: Questionable Death Resident fell multiple times due to staff neglect Staff dropped resident resulting in injuries Staff make inappropriate comments towards residents Staff don't treat residents with dignity Staff did not ensure facility was free of pests Staff do not have proper supplies for resident's hygiene needs

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a complaint investigation and deliver complaint findings. LPA Valerio met with current administrator Donnabell Galicia, and explained the purpose of the visit. The following has been determined as it relates to the following allegations: Allegation: Questionable Death This allegation was investigated under complaint #27-AS-20250522140000. The complaint finding was determined to be unsubstantiated. Continues on LIC 9099 - C... Unsubstantiated ...Continued from LIC 9099 -C, page 2 LPA Valerio was provided monthly pest control services for September, October, November and December of 2025. Reports indicate that the facility had regular check ups every other Tuesday of the month. There were reports that showed that they also came additional times. They have bait traps throughout the facility. During one of the visits on 09/02/2025, there were 12 bait traps, 9 of which had activity in the traps. Other inspections indicated that the services for pesticides were put on the outside of the facility Allegation: Staff do not have proper supplies for resident's hygiene needs According to the RP, the facility does not have wipes for the residents during changes and staff must use paper towels. LPA Valerio conducted an unannounced visit on February 03,2026. During the visit, LPA Valerio observed multiple closet areas located in the facility that stored hygiene supplies (briefs, shampoo, condition, shaving cream, hand soap, hand sanitizer, toothpaste, body lotion, body wipes etc.). According to an interview with the previous administrator Johnathan, the facility always has a stock of hygiene supplies for the residents. On April 30, 2025 LPA Valerio interviewed Staff 5 (S5). S5 is one of the few staff members that are still employed from before any management changes. S5 stated the facility has had wipes in stocked. S5 showed LPA were they would have kept them. Based on all the information collected by the Department, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the allegations occurred, therefore the allegations are UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility with Administrator Donnabell Galicia. Allegation: Resident fell multiple times due to staff neglect According to the Reporting Party (RP), Resident 1 (R1) fell multiple times. LPA Valerio requested incident reports for September and October of 2025. According to the records submitted, R1 did not have any incidents for October of 2025. In September, R1 had an unwitnessed fall on September 24, 2025. Alpha one was contacted by staff to assist the resident back up. R1 did not want to go to the emergency room. Allegation: Staff dropped resident resulting in injuries According to the RP, Resident 2 (R2) was dropped by Staff 1 (S1). RP reported that R1's toes on the right foot were scraped, left hand hurting, and had a bruise on the left leg. According to records submitted to LPA Valerio, R2 did not have any incident reports for October of 2025. LPA Valerio interviewed S1. According to S1, S1 did not provide direct care to any of the residents. S1 stated S1 was rarely in the community. R2 could not be interviewed due to no longer living in the community. Allegation: Staff make inappropriate comments towards residents/ Staff don't treat residents with dignity According to the RP, Staff 2 (S2), rude to the residents, doesn’t let them speak about concerns, talks to them like they’re dumb, makes them cry, and has no empathy for them. According to an interview with Staff 3 (S3), S2 is not rude. S3 believes "it is a language barrier and cultural thing that people find different. S3 is very loud but that is how S2 talks."According to an interview with Staff 4 (S4), S4 reported S2 being loud and has an accent but is super nice.LPA Valerio attempted to interview S2; however, S2 does not work at the facility and the last contact information is invalid. Allegation: Staff did not ensure facility was free of pests LPA Moleski conducted an unannounced visit on September 26, 2025. LPA Moleski did not indicate the observation of any pest in the community. On February 03,2026, LPA Valerio did not observe any pest in the community at the time of the visit. During this visit, LPA Valerio observed a pest control maintenance man at the facility conducting his quarterly visit. Continues on LIC 9099 - C...the state’s words, verbatim · CDSS document, Apr 30, 2026 · control 27-AS-20250925104337

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a case management visit to follow up on an incident report. LPA Valerio met with current administrator Donnabell Galicia, and explained the purpose of the visit. LPA Valerio requested the licensee send the change of administrator paperwork to LPA Valerio and LPA Jamaly by 05/01/2026. According to Unusual Incident Report submitted to the Regional Office on April 30, 2026, Resident 1 (R1) reported severe back pain, appeared appeared restless, more confused than baseline, and reported feeling very weak on April 24, 2026. Pain was rated 9/10. Vital signs were obtained, with blood pressure at 99/60 and pulse at 72. Alpha One was called; paramedics arrived and assessed the resident. Upon their arrival, the resident had difficulty getting up for transfer to the gurney. The resident was transported to Kaiser Morse Hospital for further evaluation. Resident was returned to community the same day with chronic pain and spine fractures. Resident has new prescription...Resident has to have a follow up appointment. Resident to place on status checks. Community to schedule a follow up appointment with PCP for further evaluation." LPA Valerio requested and obtained the following: Resident 1's LIC 602, Appraisal/Services and Needs Plan, and copy of incident reports for January - April 2026, and any supportive documentation No deficiencies were cited during today's visit. An exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 30, 2026

Allegation investigated: Facility refused to accept resident after being discharged from the hospital.

On 04/29/26 Licensing Program Analyst (LPA) Kimberly VIarella made an unannounced visit to this facility to complete and deliver the findings for the investigation into the above allegation. LPA announced herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator. LPA met with the new Executive Director (ED) Donnabell Galicia and a brief interview followed. The ED stated they had been at the facility for about 1 week and that they were looking forward to making improvements. This LPA inquired if they had submitted all of the paperwork for a change of administrator and the ED stated the Licensee was working on submitting the packet. LPA provided the ED with the list of the documents required. During this visit this LPA observed, 1 staff member in the lobby area answering phones and greeting people, 1 medication technician administering medications, 2 housekeepers servicing rooms, 1 Unfounded medication technician in the medication room as seen through the open door, activities staff preparing for a resident program, and 1 care staff assisting a resident with a concern in their room. LPA also observed residents chatting with members of the new management team, signing up for excursions in the log in the large common room, and one resident sitting in the lobby. Regarding the above allegation: Facility refused to accept resident after being discharged from the hospital: Based on interviews conducted with the resident (R1), Marlene Bremmer, the Interim Executive Director, and Ashley Sylve, Quality Assurance/Performance Improvement Director (RQAPID)/Designee, this LPA learned the following. On 08/22/25, R1 went to the hospital for medical treatment of a wound. While there, R1 was also diagnosed with a contagious infection and they remained at the hospital for further treatment. On 08/28/25, R1 returned to the facility from the hospital without having been re-assessed at the hospital by a member of the facility. This LPA also learned from an interview with Bremmer, that the hospital contacted Legacy Oaks to let them know that R1 had left without completing their discharge process. During that conversation, Bremmer learned from the hospital representative that R1 had identified themselves as living independently. Bremmer clarified and stated that although R1 was an independent person, R1 resided in an assisted living facility. At the time of this complaint, the census was 84 residents in care. When R1 arrived at the facility, Bremmer refused to allow R1 to stay without returning to the hospital to be reassessed. Bremmer stated, "Whenever a resident is in the hospital for 3 or more days, we always reassess their care needs in case their care plans need to be updated." Bremmer went on to say that the facility had to have the correct documentation from the hospital to establish that R1's medical condition was not a risk to other residents along with what steps the facility needed to put into place to continue to care for R1's wound. Bremmer stated, "We were not trying to evict R1, we were enforcing our infection control protocols." This LPA learned from R1 there was, "No reason they should have made me return to the hospital to wait in the ER waiting room until I could be seen again or until the facility could send someone to reassess me and allow me back." Instead, R1 told this LPA that, "I stayed at my girlfriend's house and the next day I went to my doctor." The following day R1's primary care physician cleared R1 to return to the community. R1 presented their documentation to Bremmer and arranged for home health to continue the wound care. The facility did not evict R1; it delayed R1's readmission back into the community until they could provide proper medical clearance. This process took less than 24 hours. The Department found the allegation, " "Facility refused to accept resident after being discharged from the hospital," to be UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. According to the California Code of Regulations, Title 22, there were no deficiencies observed or cited during today's visit. A copy of this report was provided and an exit interview was conduced with Galiciathe state’s words, verbatim · CDSS document, Apr 29, 2026 · control 27-AS-20250910090018

Allegation investigated: Facility staff are not providing activities for the residents in care. Facility staff are not providing transportation for residents in care

Licensing Program Analyst (LPA) Christina Valerio and LPA Reza Jamaly arrived unannounced to conduct a complaint investigation. LPAs were met by Interim Executive Director Marilyn , and explained the purpose of the visit. LPA Valerio and LPA Jamaly were provided a Termination of Employment for Staff 1 (S1), which held the position for Life Enrichment Coordinator. This position's sole responsibility was to carry out the activities planned for the community. S1 was terminated on February 13, 2026. Based on resident council meeting minutes and an interview conducted with Interim Administrator Mery Lyn Otero, they are still in process of hiring a Life Enrichment Coordinator. Continues on LIC 9099-C... Substantiated According to the Reporting Party (RP), the facility fired the staff conducting activities. During LPAs visit on April 13, 2026, LPAs observed the activities room doors to be closed with a sign stating a meeting was in progress. According to the activity schedule, Blackjack was the scheduled activity for 2:00 PM. The calendar indicated that there was nothing planned for 3:00 PM and had a letter "S" inputted on the time slot. LPAs observed residents watching television and writing for their leisure. There was not a staff led activity being held during this time. LPA Valerio and LPA Jamaly reviewed a Termination of Employment letter for Staff 2 (S2), which was the Transportation Driver. According to Interim Administrator Mery Lyn, they decided to terminate S2 because it was learned that S2 would cancel resident appointments and would not communicate with management regarding the missed appointments. LPA Valerio and LPA Jamaly reviewed resident council meeting notes dated April 2, 2026. Notes stated, "residents are not happy with transportation. There is a lack of communication and too many cancellations." According to an interview with Interim Administrator Mery Lyn, LPAs learned that S2 would show up to work late or leave work early, which caused residents to miss their appointments or scheduled outings. LPAs learned that the duties of a transportation driver include accommodating all resident appointments or outings. S2 would turn residents away if they wanted to go somewhere, such as Safeway, and did not have an appointment. LPAs learned that a new transportation driver was hired on April 13, 2026. Before this date, the facility utilized Lyft or Uber to transport residents to their appointment from April 7 - April 13, 2026. If there was an emergency, Alpha One was contacted. Per California Code of Regulations (CCR) - Title 22, deficiencies are being cited on the attached LIC 9099 - D page. Appeal rights were provided. An exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 13, 2026 · control 27-AS-20260407151307

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(f) · Plan of correction due date: May 4, 2026

87219 Planned Activities(f)In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, ... This requirement was not met as evidenced by: Based on records reviews and interviews, the licensee did not ensure the facility had a ful time person to carry out activities since Feburary 13, 2026, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 13, 2026

Plan of correction: The licensee stated they have hired a new Life Enrichment Coordinator and are waiting on the person to accept the position. Licensee to send copy of employment packet and proof of hire by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)((6) · Plan of correction due date: May 4, 2026

87464 Basic Services (f) Basic services shall at a minimum include: (6) Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by: Based on records review and interviews, the licensee did not ensure S2 provided transportation to all resident appointments, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 13, 2026

Plan of correction: The Licensee stated that they have terminated S2 on April 7, 2026 and have hired a new transportation driver on April 13, 2026. Licensee to send a copy of new employee file and copy of schedule by POC due date.

Allegation investigated: Medication: Staff are not following the medication destruction procedures

Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Legacy Oaks of Sacramento RCFE on 4/3/26 at 9:00am to inform the licensee of complaint allegation mentioned above and to deliver findings. Based on the information obtained during the investigation process, the allegation is substantiated. LPA met with interim executive director Mery lyn Otero, who provided LPA with several medication declaration forms that were not signed off appropriately as LPA observed there was no witness signature attesting the to destruction of medications. Interim administrtor admitted the policy was not being followed and provided an incident report identifying the reported inconsitancies with medication destruction documentation. It was noted that all medications allegedly destroyed without a witness were narcotic medications. All non-narcotics were witnessed. LPA observed the facility medication room to have boxes of medications that have been discontinued by resident's physician and had yet to be destroyed appropriately. Report Continued on LIC 9099-C. Substantiated The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Medication is substantiated. The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.the state’s words, verbatim · CDSS document, Apr 3, 2026 · control 27-AS-20260327094030

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(i) · Plan of correction due date: Apr 10, 2026

Incidental Medical and Dental Care: Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years...this requirement was not met as evidenced by review of facility medication destruction records where the medications allegedly destroyed were not witnessed or were missing a witness signature which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: Facility has agreed to submit a written plan of correction which includes an updated medication destruction plan to be submitted to the department by the POC due date along with signatures from all staff members with access to medications who receive training on the updated policy.

Type of visit: Case Management - Health Checks

On 03/27/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a health and wellness check. LPA arrived at 7:00 AM and reported to the front desk. LPA was greeted by one of the Medication Technicians on duty (S1). LPA identified herself, stated the purpose of the visit and asked to speak with the Designated Facility Administrator. S1 stated that they were not sure who that would be now. LPA was aware that some members of the management staff were no longer working at the facility and was present to ensure that staffing needs were appropriate to meet the needs of the residents in care. LPA asked for the names of the staff present and at the facility and stated that she would be meeting briefly with each to confirm their roles and schedules. When this LPA spoke to a Medication Technician who was filling in as a Caregiver in memory care (S2), they stated that were told to contact Lyn Otero in case of emergency as they would be the Interim Administrator for the facility. LPA instructed S2 to contact Otero. Otero identified themselves as the new Interim Administrator when they arrived at approximately 8:00 AM. This LPA confirmed that they had sent an updated LIC 308 to Community Care Licensing identifying them as the Designee. During this visit LPA observed 2 Medications Technicians in assisted living and 1 in memory care. She also observed 3 Caregivers in assisted living providing direct care. The was an additional new hire completing their new hire computer training. LPA observed 3 Staff providing direct care in memory care and no medications being administered at the time. LPA conducted a walkthrough of the building and observed staff providing breakfast to 6 residents in memory care and 2 staff providing direct care to residents. In Assisted living, LPA observed 3 residents having coffee just outside of the dining room and another resident waiting outside of the medication room for assistance. According to the California Code of Regulations, Title 22, no deficiencies were cited during today's visit. Staffing was appropriate at the time of this inspection. A copy of this report was provided and an exit interview was conducted with Otero.the state’s words, verbatim · CDSS document, Mar 27, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christina Valerio and LPA Reza Jamaly arrived unannounced to conduct a case management visit to follow up on an incident report. LPAs met with Administrator Rosalie Sullivan, and explained the purpose of the visit. On March 14, 2026, The Regional Office received an incident report and SOC 341 from the facility. The incident involved Resident 1 (R1) and Resident 2 (R2). R1 was observed by staff touching R2 and became aggressive towards staff when staff intervened. Both residents were sent out for further evaluation, responsible parties were contacted, law enforcement was contacted, and long term care ombudsman was contacted. LPAs obtained and reviewed facility documentation, such as, staff progress observation notes from the day of the incident, staff statements, and discharge plan for R1. Based on the review of documents collected and interviews conducted, no deficiencies are being cited. An exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 24, 2026

Type of visit: Office

An office meeting was held today to discuss solvency audit findings regarding Legacy Oaks of Sacramento. Present in today's meeting are: Community Care Licensing (CCL) Licensing Program Manager (LPM) Liza King acting on behalf of Regional Manager (RM) Stephenie Doub CCL Licensing Program Manager (LPM) Stephen Richardson and Lisa Rios CCL Licensing Program Analyst (LPA) Christina Valerio, Reza Jamaly, Arielle Pascua, Kesha Lewis Legacy Oaks of Sacramento Licensee Shelly Cha and Christine Soriano Legacy Oaks of Sacramento Administrator Rosalie Sullivan Legal Counsel Jake Reinhardt The solvency audit was conducted by Audit Investigator Benjamin Banahene. During today's meeting LPA Valerio and LPM Richardson reviewed the audit report finding summary. Questions from Licensee Shelly Cha regarding the findings will be sent to auditor Benjamin Benahene for further clarification. Based on the audit report findings, the licensee is in violation of the following Title 22 regulations: 1. Section 87405 – Administrator Qualifications and Duties. 2. CCR, Title 22, Division 6, Chapter 8, Section 87205, Accountability of Licensee 3. CCR, Title 22, Division 6, Chapter 8, Section 87213 - Finance; Records However, these deficiencies will be cited on Complaint # 27-AS-20250925104337 The facility will be placed on quarterly Financial Monitoring for a total of six (6) months. An exit interview was held during the Office meeting. A report will be delivered via email. Licensee to review, sign, and send report back to LPA Valerio and LPA Jamaly.the state’s words, verbatim · CDSS document, Mar 20, 2026

Allegation investigated: Staff do not prevent resident from being physically assaulted Staff do not prevent resident from being sexually asaulted

Licensing Program Analyst (LPA) Christina Valerio and LPA Reza Jamaly arrived unannounced to conduct a complaint investigation. LPAs met with Administrator Rosalie Sullivan, and explained the purpose of the visit. The following has been determined as it relates to the aforementioned allegations. The complaint investigation consisted of records review of resident files (Resident 1 (R1) - Resident 2 (R2), interviews with R1 and R2, a review of staff statements, and a review of facility records. It was alleged that R1 sexually assault R2. It was also alleged that R1 and R2 had a fight and there were no manager present. Continues on LIC 9099-C... Unsubstantiated LPA Valerio and LPA Jamaly reviewed facility records. According to an LIC 624 dated 03/12/2026, On March 12 at approx. 2:00 PM, R1 complained to Med Tech... that roommate, R2 threw a chair at R1. Resident sustained scratches on left forearm and right elbow. First aid provided by Med Tech. No other injuries observed. Resident refused to go to ER for further evaluations. 911 called and sheriff department notified. SOC 341 submitted to ombudsman. According to the LIC 624, R1 resumed usual daily activities and R2 was relocated to another room. LPAs did not observe any notes indicating sexual abuse was observed between the residents. According to the SOC 341, dated 03/12/2026, the SOC 341 reported "Care Staff alerted med tech that resident was bleeding. Med Tech gave the resident band-aids and asked what happened. [R1] stated that roommate [R2] threw a chair at R1 and in the process resident R2's glasses got broken. Residents were separated. 911 was called and an incident report number was given. Report # 26-77142" LPAs reviewed statements from staff. Statement from staff indicated that R1 is the victim of physical abuse from R2. According to a review of resident records, this incident has not happened before. Notes did not indicate any suspect of sexual abuse. According to a shift note written by Staff 1 (S1) on 03/12/2026 at 5:00 AM, R1 and R2 were arguing all night and were separated with a room change. LPAs interviewed R1. According to an interview with R1, R1 stated R2 beat R1 with a chair and sustained injuries on arm. R1 stated R1 complained to staff about R1 using most of the room and it was overbearing. R1 reported R2 was abusive by turning off the TV. R1 stated there was no sexual or physical abuse, just disturbing R1's peace. LPAs interviewed R2. Due to communication barriers, the interview was deemed unsuccessful. Based on all the information collected by the Department, although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the allegation(s) occurred, therefore these allegations are UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held with Administrator Rosalie, and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, Mar 17, 2026 · control 27-AS-20260312113254

Type of visit: Office

Office meeting conducted on 03/02/2026 via Teams meeting with the following individuals at this time: Stephenie Doub, Regional Manager Liza King, Licensing Program Manager Lisa Rios, Licensing Program Manager Charlie Yang, Licensing Program Analyst Christine Soriano, LLC Board Member Shelly Cha, LLC Board Member The purpose of this meeting was to discuss the current issues surrounding this facility at this time. It was recently learned by this licensing office that the Chief Executive Officer, CEO, Christine Soriano was removed from the board and no longer a part of operations at this time. This meeting was held to determine the course of action that the Licensee was taking in order to maintain operational stability within the governing board for this facility so as to remain in compliance at all times. The following items will need to be updated and submitted into CCL for further review: Updated LIC 500 for staff coverage and indicated days/hours for the facility designated Administrator to be present in the facility LIC 501 for the facility designated Administrator Copies of the facility utility bills for electric, water, sanitation since 01/01/2026 Letter from the Board appointing the facility designated Administrator Copy of current facility designated Administrator certificate Forms and documents for the facility designated Administrator to show that he/she does meet all educational and experience requirements Documentation that the facility designated Administrator is fingerprint cleared and properly associated to this facility Updated LIC 200 signed by the Licensee or board resolved representative Staffing projections for the next (2) weeks specifically for caregivers and medication technicians for all (3) shifts of AM, PM, and NOC Proof of current liability insurance and workman's compensation Updated LIC 610 Board resolution denoting any changes to the representative at this time All requested forms and documents are to be updated, completed, and submitted into CCL by COB of 03/04/2026 for further review by this LPA. There were no deficiencies observed or cited during today's office meeting. A copy of this report will be emailed to the address for the Licensee at shellycha81@gmail.com and a request was made by this LPA for the appointed representative to go ahead and sign the documents and scan a copy back to this LPA. Exit Interviewthe state’s words, verbatim · CDSS document, Mar 2, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst, LPA Noel Wolf Petersen arrived unannounced to 2/27/26 to assess a penalty in relation to a recent finding of a complaint 2/25/2026 where two recent cited deficiencies which were also cited with in the last year. LPA met with Care service specialist, kaitlyn Reed to explain the purpose of the visit. For a citation of section 87466, a previous citation was given on 10/2/2025. For a citation of section 87211(c), a previous citation was given on 1/14/2026. The immediate civil penalty for a repeated violation within 1 year of the previous citation, is 250$ each, a total penalty is assessed today in the amount of 500$. Appeal rights were provided, a copy of the LIC421FC's was left with the report, this report was read and given to the CSS and then a copy was sent digitialy to the administrator/ executive Director Rosalie sullivan.the state’s words, verbatim · CDSS document, Feb 27, 2026

Allegation investigated: Facility staff did not properly report incident Facility staff not answering communications from resident’s representative

Licensing Program Analyst LPA, Noel Wolf Petersen, arrived unanounced to the facility at 8:45pm to deliver findings of a complaint. LPA Met with administrator by phone and explained the purpose of the visit. In LPA's Interview with the past Administrator Johnathan Aguilar It was learned that there was a period of time from mid June to mid July 2025, where the facility was shortstaffed and unable to fulfil its regulatory obligations to report to ccl. Record review of the Incident Reports from June-July 2025 showed an observeance of timely reporting until 6/16/2025, and then a period where significant events were not reported to ccl until 7/9/2025. In that time there were 10+ events where a unplanned hospitalization exited the window of time when the event should have been reported to ccl, allong with many, many other types of report that should have been sent to the LPA. Administrator Aguilar provided this period of shortstaffing made it impossible to adequately inform and respond to communications from all resident representatives who's circumstances required notification. Continued on C- Page Substantiated Based on the departments observations and interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Citations issued on the following d-Page. A copy of the report was read to the administator and given to the administrator representative, with a copy of the appeal rights. exit interview was conducted with the current administrator. designated signatory is staff tammythe state’s words, verbatim · CDSS document, Feb 25, 2026 · control 27-AS-20250731151014

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Feb 26, 2026

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as ...deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: record review where 5 of 19 Significant Incident Reports selected randomly from the period of June 2025 to July 2025 where the facilities observed chanage in condition did not also document a notification of the residents responsible person. Interview with a previous administrator who described a period in June 2025-July 2025 where the facility was not staffed adequately to communicate with representatives. Not following this requirement poses an immediate risk to the health, safety, and personal rights clients in care.the state’s words, verbatim · CDSS document, Feb 25, 2026

Plan of correction: Review of Reporting requirements for the situations requiring communication with responsible persons will be reviewed in the mandated reporter training described below.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(c) · Plan of correction due date: Feb 26, 2026

87211(c) Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met as evidenced by: Record review where 1 of 19 significant Incident reports selected randomily from the period of june 2025 to July 2025 described an incident where one resident physically assaulted another resident 6/27/25, ccl informed and recived report 7/20/25. Interview with a previous administrator who described a period of june 2025-July 2025 where the cacility was not staffed adequately to communicate with ccl Not following this requirement poses a immediate risk to the health, safety, and personal rights clients in care.the state’s words, verbatim · CDSS document, Feb 25, 2026

Plan of correction: administrator will conduct a staff mandated reporter training, by 3/6/26. a signature of those attended will be sent to the LPA(noel.wolfpetersen@dss.ca.gov) by eod on 3/6/26.

Allegation investigated: Questionable death.

On 02/09/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings for this complaint investigation. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator. LPA met with Jonathan Aguilar and Rosaliee Sullivan the incoming ED.The three reviewed the report below. Regarding: Questionable death of a resident. A review of the resident’s (R1’s) medical records and death certificate was conducted as part of this investigation. R1 passed on 05/04/25 at their care facility. R1’s death certificate indicated Alzheimer’s as the immediate cause of death. Other significant conditions that were listed on the death certificate and contributed to their death were Parkinson’s disease and chronic pulmonary disease. No signs of a suspicious death were noted or listed on R1’s death certificate. An autopsy was not Unsubstantiated requested and law enforcement did not investigate. LPA reviewed 16 incident reports dated 12/21/24 – 05/04/25 sent to community care licensing. 5 of these reports described incidents where R1 told staff they fell and hit their head, or staff found the resident on the floor with a head wound. R1 was sent out for evaluation each time. 8 reports described R1 having a change of condition. An additional 3 reports, dated 08/02/24, 10/18/24 and 03/17/25, described medications that were not administered to R1. The report dated 08/02/24 stated that "the resident was experiencing a change of condition related to missing their medications. The MD appointment was not scheduled until September 2024; and there were no other satellite clinic appointments available. The resident was sent to the … hospital in attempt to get emergency refills for all medications to hold until the next in-person appointment in September." The report dated 10/18/24 described 10 medications that were missed for two or more days from October: 10/01/24 - 10/25/24 (25 days). The report dated 3/17/25 also stated that R1 missed doses on 2 days because the facility did not have them in stock. LPA will be following up with a case management to address R1’s repeated falls and head injuries. LPA will also address Licensee’s not ensuring that R1’s medications were in stock for administration. Regarding: Questionable death of a resident. The Department found the allegation, questionable death of a resident (R1) to be UNSUBSTANTIATED. A finding of unsubstantiated means that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. According to the California Code of Regulations, Title 22, no deficiencies were observed during today's visit. A copy of this report was provided and an exit interview was conducted with Aguilar. Another visit was conducted immediately following this one to address the other allegations that were a part of this complaint. responsible party (RP) for the 11 residents listed and interviewed those for R2 - R8. This LPA learned the following: The RP for R2 stated R2 had been utilizing a home health agency that had their own hospice agency and transitioned to that when hospice services were required. They stated that they “had a positive experience with Legacy Oaks.” The RP for R3 stated that Legacy Oaks "didn't offer us any options - they put R3 on hospice with Medical One without telling any of us. They apologized and said they were wrong and that they should have notified us." There was no notice of a change of condition, discussion about a reappraisal, and additional hospice options were not provided. The RP for R4 stated that when it became clear that hospice services were needed, "Legacy Oaks said they had an agency and gave me their card. No other hospice options were provided. The RP for R4 stated, "A very nice young lady spent hours evaluating R4 but then they said R4 was not accepted to their program. Another agency called us the next day and they took R4." The RP for R5 stated that they received a phone call from a representative at Legacy Oaks. The RP stated that this representative called and told them. “R5 is now on Medical One Hospice, did you know that?” The RP stated that they were not notified of any change of condition that would require hospice services and they were not offered any other options. The RP for R6 stated that a staff person (S10) recommended Medical One, no other options were provided. The RP explained that R6 did not renew their medical insurance and was dropped by their carrier. Since they could not pay, Medical One discontinued providing services to R6. Another hospice agency picked R6 up. The new agency was the one listed on the document provided to this LPA as they were the agency actively serving this resident at the time of this complaint; however, they started with Medical One. Regarding: Staff are coercing residents into using the facility's hospice company. The RPs for 4 different residents stated that they were not provided options for hospice services other than Medical One. The preponderance of the evidence standard has been met and the department finds the above allegation SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. Regarding: Staff are threatening residents. Regarding: Staff did not safeguard residents personal belongings. LPA learned through this investigation that resident 6, (R6) had snacks stored in their room that staff, (S9) would help themselves to during their shift. In an interview with S16, this LPA was told that R6 went to S16 crying and afraid because S9 told R6 that they would end up in Memory care. S16 asked why R9 thought they were going to memory care. R6 told them that “S9 told R6 to stop complaining to Management about them - no one was going to believe them and they were going to put R6 in memory care.” S16 brought this information to the ED who said that they would take over the investigation. The ED, Aguilar, stated that an investigation was conducted into the matter and said that they confirmed that S9 had been bullying R6 and taking their snacks. As a result of that investigation, combined with other previous offenses, S9 was terminated. This LPA also learned through interviews with S12, S16, and R6 that weeks went by before S9 was prevented from taking R6's personal property. LPA asked how long, R6 responded weeks, but I don't know how many. S12 stated that at the time there were a few employees suspected of stealing from residents. S9 was one of them. Another resident, (R8) told S12 that they woke up once and saw S9 going through their things when they had no reason to be in R8's room. S12 stated that they knew management had been informed of the situation by S16, but nothing was done about it for weeks. "It was even brought up in stand-up." LPA Viarella interviewed S6 and asked what happened when they went to management regarding S9 taking their food and threatening them. R6 said at first they said they would look into it, but nothing happened. S9 kept doing it. Then they reassigned S9 so they wouldn't even a reason to come to my room, but S9 still came and told me to stop complaining. Eventually it stopped but it took a while. LPA asked which members of management R6 spoke with and R6 said they didn't want to talk about it anymore, they were just glad it stopped. Regarding: Staff are threatening residents. Regarding: Staff did not safeguard residents personal belongings. The standard for the preponderance of evidence has been met and the department found the above allegations to be SUBSTANTIATED. These deficiencies have been cited on the LIC 9099D page. Regarding: Staff are not adequately supervising residents at night. This LPA interviewed the Designated Facility Administrator / Executive Director (ED) Jonathan Aguilar, regarding company policy. Aguilar stated that staff were to be "awake during their shifts and at no time sleeping on the sofas throughout the building." LPA observed that the Plan of Operation had a section titled "Awake Night Staff: Staff members were scheduled to be alert and on-duty during overnight hours to monitor and support residents requiring nighttime supervision." This LPA conducted 5 interviews, 2 residents and 3 staff R4, R7, S3, S4 and S5. R4 stated they had seen staff sleeping on the sofas in the hallways of the assisted living area. LPA stated that this complaint was opened on 05/22/25 and asked if this was occurring back then as well. R4 said yes. "Some of the staff that used to do it a lot aren't here anymore, but it still happens sometimes, not as much as it used to, but I have seen it." R7 also stated that they had seen staff sleeping on the sofas during the overnight shift too. S5 stated they had seen staff sleeping on the sofas in both the assisted living area and memory care. S4 and S5 stated that S6 had 2 disciplinary warnings for sleeping while on duty. LPA asked the ED for a copy of S6's personnel file. The ED was unable to locate it; however, he was able to provide this LPA with a copy of the second warning dated 11/10/25. It stated, "The employee was observed sleeping during their scheduled shift." Regarding: Staff are not adequately supervising residents at night. 2 residents and 3 staff stated that staff have been seen sleeping during their shifts. The standard for the preponderance of evidence has been met and the department found the above allegation to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. Regarding: Staff are not following residents care plans. When S5 was asked if care plans were being followed, S5 stated that, that "Residents are not getting the showers they are supposed to. S5 stated that when they get a refusal, they change their approach or do a change of face. Others don't bother. There are some refusals, but some caregivers are just lazy." While reviewing personnel files, this LPA observed that 4 staff members (S20-S24) received disciplinary warning notices on 10/24/25. The warnings were for not documenting “the resident’s refusal to participate in the scheduled shower on (dates listed were 10/24/25, 10/11/25, 09/06/25, 09/13/25 Based on a document review, MedTech, S7 did not complete any annual MedTech training in 2025 and only 2 hours of dementia care training. LPA reviewed the personnel file for S7 and found that on 10/12/25 S7 stated, “I was giving four people meds at the same time.” S7 gave a medication (Atorvastatin 40mg) intended for resident (R9) to resident (R10). LPA also reviewed a 30-Day Performance Improvement Plan (PIP) for S7 with a start date of 12/03/25. It stated “The employee failed to consistently follow established protocols for ordering, tracking, and verifying medications This appears to be caused by a lack of adherence to procedure and inconsistent follow-up on assigned responsibilities. The employee did not consistently communicate or follow-up with physicians (MD) and responsible parties (RP) regarding medication issues in a timely manner. This was due to inadequate prioritization of critical communications and insufficient attention to follow-up requirements. The employee failed to submit an incident report for a missing medication as required by company policy and regulatory standards. This was caused by neglect of reporting responsibilities and failure to recognize the critical importance of documentation for compliance and resident safety.” There was a sheet for S7’s supervisor to list “Goal” and to provide “Status and Comments” along with dates for progress checking. They were listed: 12/10/25, 12/17/25, 12/24/25 and 01/03/26. None were filled out. Regarding: Staff are not following resident care plans. The standard for the preponderance of evidence has been met and the department found the above allegation to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. Regarding: Staff handled resident in a rough manner. LPA interviewed 2 staff S5 and S16 regarding a particular incident that took place in memory care where it was alleged that a third staff member, S7 roughly handled a resident. Due to the cognitive impairments of the 2 residents involved, neither were considered credible witnesses to interview. S16 stated they saw S7 put their hands on R10 and pushed them down onto the sofa in memory care all the while screaming at R10. S16 said that R10 had curled up on their side in a fetal position and was visibly frightened. S5 stated they did see S6 get between R10 and R5. S5 stated that R10 was grabbing at R5 and S6 stepped between them and told R5 to sit down. S6 did put their hands on R10 and pushed them down onto the sofa. Regarding: Staff handled resident in a rough manner. The standard for the preponderance of evidence has been met and the department found the above allegation to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. respectively) was not documents in either the Shower Refusal Form, the Shower Sheet, or ALIS (the computer system). This omission represents a lapse in required documentation and poses a potential compliance risk with care plan protocols and regulatory standards.” All 4 staff members signed an acknowledgement of warning. During the course of this investigation, this LPA also learned from Ashley Sylve and Jonathan Aguilar that the facility went from 3 MedTechs per shift to 2. S5 stated that "the most important way they are not following them (care plans) has to do with medications. They do meds in assisted living before memory care. Some of our residents are suppose to get their first meds and 7:00 AM (before breakfast) and they aren't getting them until 11:00 AM and that messes up the second pass because it's too soon. They aren't following the doctor's orders and it has gotten worse since we have gone down to 2 MedTechs." While reviewing personnel files for MedTechs, this LPA found a Counseling Documentation Form for S7 dated 01/08 25. The first page of the document included the following: “Level of Corrective Action – Final Warning. Nature of Violation – Policy or Safety Violation. Incident Summary: It has been observed and documented that multiple medication technicians have failed to consistently follow established policies and procedures regarding medication management. The following areas of concern have been identified: 1. Documentation Errors: Instances of incomplete, inaccurate or later entries in the EMAR system. 2. Medication Handling: Failure to adhere to proper medication storage, distribution, and disposal protocols. 3. Communication Failures: Instances where medication discrepancies or issues were not promptly reported to supervisors or healthcare providers as required.” “Goals /Corrective Actions” were then listed along with sections for S7 to offer an explanation or rebuttal. These sections were blank. The form was then signed by S7, their supervisor and dated 01/08/25. Because the form stated that “multiple medication technicians had failed to consistently follow established procedures regarding medication management,” this LPA contacted the current Executive Director (ED), Jonathan Aguilar for clarification. Aguilar stated that it was his first day at Legacy Oaks and was completing his on boarding, but that the ED at the time, Ashley Sylve, had written up all 12-14 medication technicians as they all had not been following proper procedures and protocols. Aguilar stated that “the meeting was 2-3 hours long and that the MedTechs all participated in a refresher training session.” According to the California Code of Regulations, Title 22, no other deficiencies were observed during today's visit. Due to time constraints, a case management will be conducted at a later date to address the additional deficiencies observed during this investigation. A copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Aguilar.the state’s words, verbatim · CDSS document, Feb 9, 2026 · control 27-AS-20250522140000

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(7) · Plan of correction due date: Feb 10, 2026

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents...(7) To fully participate in planning their care... and services to be provided... The licensee shall provide necessary information.. The Licensee did not meet this requirement as evidence by: Based on interview and record review, the RPs for 4 different residents stated that they were not provided options for hospice services other than Medical One. This posed/poses an immediate risk to the health, safety, and/or personal rights of residents in care.the state’s words, verbatim · CDSS document, Feb 9, 2026

Plan of correction: The facility stated they will conduct a training with managers regarding this regulation today. By close of business tomorrow an attestation will be signed by all managers that will include the regulation and their understanding of it. This will be emailed to CCLASCPSacramentoSouthRO@dss.ca.gov and a copy to Stephen.Richardson@dss.ca.gov by COB 02/10/26 Sullivan also stated that this regulation will be included in the all staff and emphasized that at least 3 hospice options will be provided.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Feb 10, 2026

(a)In addition to the rights listed in Section 87468.1, Personal Rights of...(8) To be free from neglect, financial exploitation... punishment, humiliation, intimidation, and verbal, mental, ... The Licensee did not meet this requirement as evidence by: Based on interviews with R6, S12, S16 and the ED, S9 was threatening R6. This posed/poses an immediate risk to the health, safety, and/or personal rights of residents in care.the state’s words, verbatim · CDSS document, Feb 9, 2026

Plan of correction: Facility will be supplying CCL with the name of an outside trainer (Ombudsman or Hospice)and the date that they will collaborate on to conduct an in-service on Personal Rights and Abuse. This will be submitting by the COB 02/10/26

From the deficiency page — Deficiency type: Type A · Section cited: CCR 874682.2(25) · Plan of correction due date: Feb 10, 2026

(a)In addition to the rights listed in Section 87468.1...(25) To protection of their property from theft or loss according to Health and Safety Code sections... The Licensee did not meet this requirement as evidence by: Based on interviews with R6, S12, S16 and the ED, S9 was taking food from R6's room. This posed/poses an immediate risk to the health, safety, and/or personal rights of residents in care.the state’s words, verbatim · CDSS document, Feb 9, 2026

Plan of correction: Facility will submit a plan to conductedt a training for all staff on the theft and loss policy and how theft and loss are related to residents personal rights. This plan will be submitting by the COB 02/10/26 and signature sheets will be submittied when the training is completed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Feb 10, 2026

Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.… The Licensee did not meet this requirement as evidence by: Based on interviews, 2 residents and 3 staff (R4, R7, S3, S4 and S5) stated that staff have been seen sleeping during their shifts. This posed/poses an immediate risk to the health, safety, and/or personal rights of residents in care.the state’s words, verbatim · CDSS document, Feb 9, 2026

Plan of correction: Facility will submit a plan for unannounced check-ins after hours to ensure that staff are awake and alert as required. This plan will be submitted by the COB of 02/09/26 to CCL.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 10, 2026

(a) A plan for incidental medical and dental care shall be developed ...(4) The licensee shall assist residents with self administered medications as needed. The Licensee did not meet this requirement as evidence by: Based on interviews with the ED and S5 and a record review of S7's personnel files, the licensee did not ensure that staff assisted residents with self administered medications as needed per their care plans. This posed/poses an immediate risk to the health, safety, and/or personal rights of residents in care.the state’s words, verbatim · CDSS document, Feb 9, 2026

Plan of correction: The facility has contracted with a pharmacy to obtain a 10-day emergency supply of medications when necessary to prevent residents from missing prescribed meds. Facility will supply documentation regarding this new agreement/procedure. This will be done by COB 02/09/26.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1569.626(a) · Plan of correction due date: Feb 10, 2026

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: The Licensee did not meet this requirement as evidence by: Based on record review S7 only had 2 hours of dementia care training and had not completed the required number. This posed/poses an immediate risk to the health, safety, and/or personal rights of residents in care.the state’s words, verbatim · CDSS document, Feb 9, 2026

Plan of correction: Facility will submit updated audit of annual dementia care training to CCL and a timeline for completion by COB, 02/09/26.

Type of visit: Case Management - Deficiencies

On 01/14/26, Licensing Program Analyst (LPA) Kimberly Viarella made unannounced visit to this facility to conduct a case management visit regarding an SOC 341 that was reported to Community Care Licensing. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator/Executive Director (ED). LPA met with Jonathan Aguilar and a brief meeting followed. Community Care Licensing received an SOC 341 on 1/13/26 for an incident involving 2 residents in memory care on 01/05/26. This was a violation of reporting requirements as the report should have been submitted within 24 hours. Upon review of personnel records, not all of the staff working in memory care at the time of the incident had all of the required dementia care training. LPA reviewed training materials for S1 who did not have any of their annual training completed for 2025. These 2 deficiencies were cited on the LIC809D page. According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit. A copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Aguilar.the state’s words, verbatim · CDSS document, Jan 14, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Jan 23, 2026

Reporting Requirements 87211 (c) Any suspected physical abuse...an elder or dependent adult shall be reported...within 24 hours as required by Welfare and Institutions Code Section 15630(b)(1). The Licensee did not meet this requirement as evidenced by: Based on document review, the facility sent an SOC 341 on 1/13/26 for an incident that occurred on 1/5/26. The facility did not meet the 24 hour reporting requirement. This posed a potential threat to the health, safety, and/or personal rights of residents in care.the state’s words, verbatim · CDSS document, Jan 14, 2026

Plan of correction: ED stated they will be doing a coaching/training session with all managers to ensure that reporting requirements will be met going forward. A signature sheet will be provided to CCL by 1/23/26 as proof of correction.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(c)(1)(B) · Plan of correction due date: Feb 28, 2026

Personnel Records 87412(c) Licensees shall maintain... verification of required staff training and orientation. (1) The following staff training (B) For staff who provide direct care to residents with dementia...dementia special care, programming ... The Licensee did not meet this requirement as evidenced by: Based on a review of S1's file, they did not have the required dementia care training pre regulations. This posed a potential threat to the health, safety, and/or personal rights of residents in care.the state’s words, verbatim · CDSS document, Jan 14, 2026

Plan of correction: ED stated that they will have all dementia care training completed for all staff by 2/13/26. LPA to conduct a POC visit and review logs to ensure compliance.

Type of visit: Required - 1 Year

On 12/18/25, Licensing Program Analysts, (LPAs) Kimberly Viarella and Arvin Villanueva made an unannounced visit to this facility to conduct the annual inspection. LPAs identified themselves upon arrival, stated the purpose, of the visit, and asked to meet with the Designated Facility Administrator / Executive Director (ED). LPAs met with ED Jonathan Aguilar and a brief meeting followed. LPA's began the visit with by ensuring that all the staff had the required background clearances necessary to work with residents in care. All were in compliance at the time of this inspection. LPA Viarella reviewed 3 staff files to ensure that they had the required health clearances, and training. 2 of the 3 files did not have the annual training required at the time of this inspection. This deficiency will be cited on the LIC 9099 during the second part of this annual inspection. 2 of the 3 files did not have updated certifications required, but they were produced upon request. LPAs conducted a walkthrough of the building and observed 9 residents playing Bingo in the front activity room of Assisted Living and led by the Activities Assistant. LPAs also observed that the hallway in the rear of the building near room 42 was cold, however, LPAs observed that the back door was propped open. Upon closing the door, the temperature began to rise quickly in the area. The hot water in room 31 was measured to ensure it was in compliance and between 105 and 120 degrees Fahrenheit. It measured 102 degrees and was not in compliance. Hot water in room 42 measured 117 degrees Fahrenheit. LPAs will measure the hot water again upon their return to ensure consistency and compliance. Due to time constraints, LPAs will have to return at a later date to complete this inspection. According to the California Code of Regulations, Title 22, no deficiencies were cited today. A copy of this report was provided and an exit interview was conducted with Aguilar.the state’s words, verbatim · CDSS document, Dec 18, 2025

Allegation investigated: Facility is in disrepair.

On 12/09/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to deliver complaint findings. LPA met with Facility Designated Administrator (FDA), Jonathan Aguilar and explained the purpose of the visit. Current census was 78. A brief interview with FDA Aguilar was conducted. Allegation: Facility is in disrepair It was alleged that the facility is in disrepair. During the course of this investigation, LPA Pascua conducted interviews and conducted a tour of the facility. Based on the interviews conducted, facility staff acknowledged that the facility is in disrepair. Staff reported that portions of the flooring in the memory care building have lifted and were covered with furniture to conceal that the floors have not been properly repaired. Substantiated Two residents stated that they occasionally experience delays in receiving assistance with their daily needs but noted that the situation has been improving. The remaining three residents reported that they seldom experience any issues.A facility staff member reported that there are six caregivers and two medication technicians assigned to both the AM and PM shifts, and a total of five staff members assigned to the NOC shift. A review of the facility’s staffing schedules corroborated this information. Based on the information gathered, there is not sufficient evidence to prove that due to lack of staff the facility cannot meet the residents needs. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report was provided to the facility at the end of this visit. During a facility visit by the Department on 11/13/2025, it was observed that the main hallway in the memory care building also had lifted flooring and was in disrepair. Staff confirmed that these areas required repair. Additional observations were made by LPA Pascua. LPA Pascua and FDA Aguilar toured 10 resident bedrooms and common areas, including the living area, activity area, and main hallways. The majority of the 10 resident bedrooms had significant flooring lift. In addition, some ceiling tiles had been removed or were missing. Furthermore, LPA Pascua observed a large portion of the facility’s roofing that showed visible wear and tear and contained an opening. Based on the information gathered through observation and record reviewed, the preponderance of evidence was met, therefore the above allegations noted were SUBSTANTIATED. One deficiency was cited An exit interview was conducted with FDA Aguilar and a copy of the reports were provided at the end of the visit.the state’s words, verbatim · CDSS document, Dec 9, 2025 · control 27-AS-20250925100233

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jan 9, 2026

(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 is not met as evidenced by: Based on observationa and interview, the licensee did not ensure that the facility has been maintained overtime. During the course of the LPAs visits, several floors and tiles were observed to be lifting off the ground. This poses a potential, health,safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Dec 9, 2025

Plan of correction: The facility administrator states that the facility has implemented a plan in place to ensure that the flooring will be repaired. This facility has also agreed to TSP Services. A statement of correction with the plan in place will be sent to the LPA by POC date.

Type of visit: Case Management - Deficiencies

On 10/23/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a follow up a case management visit regarding the deficiencies observed during a complaint investigation (# 27-AS-20250804095207) visit on 08/06/25. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator / Executive Director (ED). LPA met with ED Jonathan Aguilar and Ashley Sylve the Quality Assurance/Performance Improvement Director (RQAPID). A brief meeting followed. During this LPA's tour of the facility on 08/06/25, this LPA observed the following: LPA observed an unlocked laundry room with toxic chemicals accessible to residents in care. LPA also observed Clorox bathroom cleaner and Crest mouth wash under the sink in room (#37). These were violations of the California Code of Regulation (CCR) 87309, "Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage." This LPA also observed the door to the Medication Room in Assisted Living was open and the keys to the medication cart were in its lock. No staff were present in the medication room or the room that was being used as an office attached to it. This was a violation of CCR 87465 "Incidental Medical and Dental, "(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication." When this LPA toured the facility and tested the rear delay egress door in the Memory Care Community, the door opened without delay and the alarm did not sound. This was a violation under Health and Safety Code, "1569.699(a) Exit doors; egress-control devices of time-delay type; fences. H&S 15699(a) states, "(a) When approved by the person responsible for enforcement, as described in Section 13146, exit doors in facilities classified as Group R, Division 2 facilities under the California Building Standards Code, licensed as residential care facilities for the elderly, and housing clients with Alzheimer’s disease or major neurocognitive disorder, may be equipped with approved listed special egress-control devices of the time-delay type, provided the building is protected throughout by an approved automatic sprinkler system and an approved automatic smoke-detection system. The devices shall conform to all of the following requirements:…" LPA observed that both the entrance door to the Business Office, and its interior door to the smaller office within, were open and a file drawer was left open leaving residents confidential financial information accessible. This was a violation under Additional Personal Rights of Residents in Privately Operated Facilities CCR, 87468.2 "(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: (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law." These deficiencies were cited on the attached LIC 809D pages. LPA also observed during today's visit that an Activities Director/Life Enrichment Coordinator has not been hired yet. The previous person was laid off in September. LPA asked the ED what plans were in motion to fill the position. LPA provided technical assistance and referred to CCR Planned Activities 87219 (a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include: (1) Socialization to promote or enhance personal relationships. Activities may include, but are not limited, to: (A) Group discussion and conversation. (B) Reminiscence activities, such as looking at photos, letters, or greeting cards. (C) Cultural and/or religious activities, such as holiday celebrations and cultural traditions. (D) Other social activities such as arts, crafts, games, gardening, pet care, and other recreational activities promoting social interaction. (2) Daily living skills/activities which foster and maintain independent functioning. (3) Cognitive and mental stimulation activities such as reading, writing, movies, crossword puzzles, board and card games, and using the computer. (4) Sensory stimulation, such as music therapy and aromatherapy, or tactile activities, such as pet therapy. (5) Leisure time activities cultivating personal interests and pursuits, and encouraging leisure-time activities with other residents. (6) Physical activities that maintain physical health including games, sports, exercises, and other similar activities that promote balance, strength, coordination, flexibility, and range of motion. (7) Education, achieved through special classes or activities. (8) Provision for free time so residents may engage in activities of their own choosing. (b) Residents served shall be encouraged to contribute to the planning, preparation, conduct, clean-up and critique of the planned activities. (c) The licensee shall arrange for utilization of available community resources through contact with organizations and volunteers to promote resident participation in community-centered activities which may include: (1) Attendance at the place of worship of the resident's choice. (2) Service activities for the community. (3) Community events such as concerts, tours and plays. (4) Participation in community organized group activities, such as senior citizen groups, sports leagues and service clubs. (d) In facilities licensed for seven (7) or more persons, notices of planned activities shall be posted in a central location readily accessible to residents, relatives, and representatives of placement and referral agencies. Copies shall be retained for at least six (6) months. (e) In facilities licensed for sixteen (16) to forty-nine (49) persons, one staff member, designated by the administrator, shall have primary responsibility for the organization, conduct and evaluation of planned activities. This person shall have had at least six (6) months experience in providing planned activities or have completed or be enrolled in an appropriate education or training program. (f) In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities. The program of activities shall be written, planned in advance, kept up-to-date, and made available to all residents. The responsible employee shall have had at least one year of experience in conducting group activities and be knowledgeable in evaluating resident needs, supervising other employees, and in training volunteers. LPA requested a plan be submitted to Community Care Licensing for how/when the facility will fill the full-time 40 hour, on site, position ensuring that the candidate meets all of the qualifications required in Title 22. According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit, a copy of this report was provided along with APPEAL RIGHTS, and an exit interview was conducted with Aguilar and Sylve.the state’s words, verbatim · CDSS document, Oct 23, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Oct 24, 2025

"Storage Space and Access (a) Except as specified in subsection (b)...cleaning solutions, poisonous substances...danger to residents are in locked storage and are not left unattended if outside the locked storage." The Licensee did not meet the above requirement when: LPA observed an unlocked laundry room with toxic chemicals accessible to residents in care. LPA also observed Clorox bathroom cleaner and Crest mouth wash under the sink in the bathroom of the behavioral intervention room (#37). This posed an immediate risk to the health safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 23, 2025

Plan of correction: The ED stated that the locks on the laundry room (and Business Office ) have been replaced with key codes and now the doors lock automatically upon closing. LPA observed locks during this visit. This POC has been cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Oct 24, 2025

87465 "Incidental Medical and Dental (h) The following requirements shall apply...(2)...medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... The Licensee did not meet the above requirement when: This LPA observed the door to the Medication Room in Assisted Living was open and the keys to the medication cart were in its lock. This posed an immediate risk to the health safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 23, 2025

Plan of correction: ED stated this occurred during his paternity leave and he learned that staff had been getting contradictory information about the appropriateness of keeping the med room door open. Since then there has since been additional training and the lock on that door has also been changed to lock upon closing. The ED will submit the updated Med Room Policy to CCL by COB 10/24/25 as well as signature sheets for addtional training to be completed by 10/30/25. These documents will be submitted to CCLASCPSacramentoRO@dss.ca.gov.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 15699(a) · Plan of correction due date: Oct 24, 2025

15699(a) states, "(a) When approved by the person responsible...special egress-control devices of the time-delay type, ...The devices shall conform to all of the following requirements:…" The Licensee did not meet the above requirement when: When this LPA toured the facility and tested the rear delay egress door in the Memory Care Community, the door opened without delay and the alarm did not sound. This posed an immediate risk to the health safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 23, 2025

Plan of correction: ED stated that they will submit the updated policy regarding the use of the delayed egress door by tomorrow COB 10/24/25 and will supply signature sheets from staff training to be completed by 10/24/25. These documents will be emailed toCCLASCPSacramentoRO@dss.ca.gov.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: Oct 31, 2025

Additional Personal Rights of Residents in Privately Operated Facilities CCR 87468.2 "(a) In addition... Residents in All Facilities...rights: (2) To have their records and personal information remain confidential... The Licensee did not meet the above regulation when: LPA observed that both the entrance door to the Business Office, and its interior door to the smaller office inside, were open and a file drawer was left open leaving residents confidential financial information available. This posed a potential threat to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 23, 2025

Plan of correction: The ED stated that the locks on the laundry room (and Business Office ) have been replaced with key codes and now the doors lock automatically upon closing. LPA observed locks during this visit. This POC has been cleared.

Allegation investigated: Staff did not ensure that facility A/C is operable.

On 10/3/25, Licensing Program Analysts (LPAs) Cynthia Tamayo and Arvin Villanueva made an unannounced visit to this facility to close and deliver investigation findings into the above allegation. LPAs identified themselves upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator (DFA). LPAs met with DFA, Ashley Sylve, and a brief meeting followed. It was alleged that staff did not ensure that facility A/C is operable. on 7/29/25 and 8/21/25, LPA Tamayo toured the facility including common areas and resident bedrooms. During the facility tours, it was observed resident rooms were between 78- 85 degrees, however, it was observed that the temperature was over 85 degrees in common areas such as the hallway near the dining room and server room on these dates, which is not within Title 22 regulations. Continued on 9099-C Substantiated On 8/25/25 the outdoor temperature was 105 degrees F* and the facility interiors (bedrooms and common areas) were not 30 degrees below outdoor temp (75 degrees). The use of the Infrared thermometer gun, wall thermostats, and observations were used to determine temperatures. Staff interviews, resident interviews, and observations determined that at least two thermostats in the hallway and three resident bedrooms were not functioning properly. Residents and staff confirmed staff are verbally notified if their room is not cooling, in which a maintenance ticket is created and the maintenance worker offers to install a standing/portable AC units and /or fans. Staff have placed standing/portable AC units in resident rooms when the central AC is not cooling all rooms properly, in which portable cooling units or switching rooms were offered to residents. Staff reported that historically the AC has not operated as it should, especially in the summertime and have put standing AC/portable AC units and/or fans in resident bedrooms as needed as a temporary solution. Staff admitted the AC unit is not always in working in good condition and there is an ongoing issues with the AC unit in the building. On 8/21/25, the DFA stated the facility was in the process of obtaining bids to install a more permanent solution in the server room and hallway area in which there is lack of ventilation as well as possibly some swap coolers. During this visit, on 10/3/25, DFA stated the facility is actively working to resolve the AC unit issue and there is improvement on this matter. DFA also stated the facility started to routinely change out air filters as of 9/15/25. DFA stated that changing out air filters has helped the AC unit function properly, as it is not working as hard. The facility is able to maintain an average between 75-80 degrees in the past month. Residents in rooms 36-71 have been relocated as the rooms are undergoing renovation to ensure all furnishings are operating properly, including the air conditioner and plumbing. Based on observations, record review, and interviews, the allegation that staff did not ensure that facility A/C is operable SUBSTANTIATED. Based on the information gathered through observation and record reviewed, the preponderance of evidence was met, therefore the above allegations noted were SUBSTANTIATED. one deficiency was cited (See LIC809D). An exit interview was conducted with DFA and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility. On 08/13/25, Licensing Program Analyst (LPA) Kimberly Viarella substantiated an allegation that staff are mismanaging resident's medications. Additionally, LPA Viarella is working with the facility to address issues around the facility not submitting timely reporting requirements. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred at this time. Based on observations, record review, and interviews, the allegation that staff are administering the incorrect medication to residents in care is UNSUBSTANTIATED but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies cited per California Code Regulation, TITLE 22 regarding this allegation. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 3, 2025 · control 27-AS-20250725171604

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303 · Plan of correction due date: Oct 10, 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 regulation was not met as evidenced by based on observation and interviews that took place on 7/29/25 and 8/21/25, which corroborate the conditioning system was not fully functioning and maintained in good repair especially on dates of exreme heat. Additionally, one hallway area was recorded to be over 85 degrees on these dates. This poses an potential health and safety risk to residents in care, especially those with medical conditions impacted by heat.the state’s words, verbatim · CDSS document, Oct 3, 2025

Plan of correction: The facility shall submit a plan for the repair and/or replacement of the air conditioning system to ensure the facility has an adequate cooling system in good working order along with documentation of the service invoice or technician report by POC due date. In the interim, the facility will implement and document temporary cooling measures (e.g., portable air conditioners, fans, relocating residents to cooler areas) to ensure resident comfort and safety.

Allegation investigated: Questionable Death

Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to deliver findings on this complaint. LPA Moleski met with facility administrator Ashley Sylve and explained the purpose of the visit. LPA Moleski reviewed a death report for (R1). R1 was found unresponsive on the morning on 1/29/25. First responders declared R1 dead as of 8:30 a.m. R1 was 90 years old, and had a primary diagnosis of atrial fibrillation, diabetes, Hodgkin lymphoma, and had a history of stroke, according to their resident file. R1 was not receiving hospice care. The Community Care Licensing Division (CCLD) reviewed a death certificate for R1. R1's immediate cause of death was identified as a heart attack, with leading causes of myocardial hypotension, myocardial infarction, and coronary artery disease. [continued on 9099-C] Unsubstantiated An incident report submitted to CCLD regarding the circumstances of R1's death indicated that first responders estimated R1's time of death as some time "earlier that morning" based on R1's body temperature and the rigor mortis present in R1's body. LPA Moleski reviewed R1's care plan, dated 1/6/25. R1 was required to have checks every two hours, per the care plan. R1's appraisal, dated 1/6/25, indicated that R1 required special observation and/or night supervision. The appraisal was signed by Sylve on 1/6/25. LPA Moleski reviewed witness statements taken by facility staff regarding R1's death. Staff members who observed R1 on the evening of 1/28/25 indicated that R1 appeared normal, and was observed sitting up. An overnight caregiver on duty assigned to R1's care (S10) said in a statement that they had given water to R1 around 11 p.m. on 1/28/29, and passed by R1's room again around 2 a.m. and saw R1 asleep. Witness statements do not indicate that any additional contact was made with R1 until R1 was found unresponsive by housekeeping staff in the morning. In a statement, one staff member who alerted first responders to R1's condition (S11) said EMTs estimated R1 had died "during the overnight hours based on [R1's] physical state." LPA Moleski reviewed R1's call button responses and observed R1's last call for assistance was just before 11 p.m., presumably when S10 provided R1 with water. In an interview, Sylve said that, based on witness statements, the last time R1 was checked on was at 2 a.m. The department has determined the following as it relates to the allegation that facility staff are not checking on residents during their shifts: Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Section 87466. An exit interview was held with Sylve. A copy of this report and appeal rights were left with Sylve. Although R1's death was reported to the local coroner's office, no autopsy or biopsy were performed, and R1's death certificate did not indicate the death was suspicious. LPA Moleski reviewed witness statements taken by facility staff regarding R1's death. Staff members who observed R1 on the evening of 1/28/25 indicated that R1 appeared normal, and was observed sitting up. An overnight caregiver on duty assigned to R1's care (S10) said in a statement that they had given water to R1 around 11 p.m. on 1/28/29, and passed by R1's room again around 2 a.m. and saw R1 asleep. Witness statements do not indicate that any additional contact was made with R1 until R1 was found unresponsive by housekeeping staff in the morning. The department has determined the following as it relates to the allegation of a questionable death: Based on record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Sylve.the state’s words, verbatim · CDSS document, Oct 2, 2025 · control 27-AS-20250131105732

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Oct 3, 2025

"The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs..." This requirement was not met as evidenced by: Based on record review and interviews, a resident required two hour checks per their care plan, but did not receive these checks on the night of their death, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Oct 2, 2025

Plan of correction: Licensee agrees to provide LPA Moleski a written plan to address two hour checks by POC due date, with additional training to follow. vincent.moleski@dss.ca.gov

Allegation investigated: Staff keep taking residents pendent away.

On 09/25/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to deliver the findings of this investigation into the above complaint. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Ashley Sylve, the Quality Assurance/Performance Improvement Director (RQAPID)/Designee. LPA met with Sylve and a brief meeting followed. LPA conducted interviews and a review of records during the course of this investigation. This LPA interviewed staff S1-S4. This LPA learned from S2, S3, and S4, that when staff would assist the resident (R1) with meals, changing, or showers, they would remove the pendent and put it on the small table in R1's room, which was out of R1's reach. They would then return the pendant to R1's neck following the activity. S2, S3, and S4 all mentioned the possibility that staff sometimes forgot to put the pendant back on R1 after they provided assistance with activities of daily living. That being said, 3 out of the 4 staff interviewed stated they had personally seen the pendent on the table out of R1's reach and each Unsubstantiated stated that when they did, they put it back around R1's neck. Based on a review of the pendant call alert, there were days when either R1 did not have a pendant (both the family and facility staff commented that it had been lost and replaced) or it was not activated. This LPA learned the following from a review of the call logs. From 05/01/25 though 05/14/25, R1 activated their pendant 66 times, out of that number, 11 of these calls for assistance took longer than 15 minutes to respond to. On 05/01/25, It took staff 2 hours and 26 minutes to address R1's call. On 05/02/25, it took 1 hour and 2 minutes. On 05/06/25, it took another 1 hour and 2 minutes. On 05/08/25, it took 31 minutes, and on 05/09/25, it took 1 hour and 20 minutes. The Department found the allegation "Staff keep taking residents pendent away," UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. However, during this investigation the Department also learned that staff were not responding to the resident's call alert in a timely manner and that deficiency will be addressed during a future case management visit. According to the California Code of Regulations, Title 22, no deficiencies were cited during today's visit and a copy of this report was provided along with APPEAL Rights and an exit interview was conducted with Sylve.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 27-AS-20250424084313

Type of visit: Case Management - Deficiencies

On 09/25/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to conduct a case management as a follow-up on complaint number 27-AS-20250424084313 closed earlier today. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with Ashley Sylve, the Quality Assurance/Performance Improvement Director (RQAPID)/Designee. LPA met with Sylve and a brief meeting followed. During the course of that investigation, this LPA learned the following. Based on a review of the pendant call alert, there were days when either R1 did not have a pendant (both the family and facility staff commented that it had been lost and replaced). This LPA learned the following from a review of the call logs. From 05/01/25 though 05/14/25, R1 activated their pendant 66 times, out of that number, 11 of these calls for assistance took longer than 15 minutes to respond to. On 05/01/25, It took staff 2 hours and 26 minutes to address R1's call. On 05/02/25, it took 1 hour and 2 minutes. On 05/06/25, it took another 1 hour and 2 minutes. On 05/08/25, it took 31 minutes, and on 05/09/25, it took 1 hours and 20 minutes. According to the California Code of Regulations (CCR) Title 22, the Licensee did not ensure that CCR 87411(a) was followed. This regulation requires the Licensee to provide "care and supervision as necessary to meet the residents' needs." This deficiency was cited on the LIC 809 D page. There were no other deficiencies cited during today's visit. A copy of this report was provided along with APPEAL Rights and an exit interview was conducted with Sylve.the state’s words, verbatim · CDSS document, Sep 25, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Oct 17, 2025

87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... The Licensee did not meet the above requirement when: Based on a review of records, in 11 out of 66 occurrences, staff did not respond to a resident's call light in a timely manner with 4 of those response times being in excess of 1 hour. That posed/es a potential risk to the health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: The Designee informed this LPA that they will include call light response procedures during daily standup until a formal retraining for all staff can be conducted prior to 10/17/25. The Designee will then send signature sheets from participants to CLL for proof of correction.

Allegation investigated: Facility not ensuring that smokers and smoke do not block public access.

Licensing Program Analyst(LPA) Noel Wolf Petersen, arrived unannounced on 9/23/25 at 10:00 to conduct a complaint investigation, LPA met with the administrator Ashley Sylv and explained the purpose of the visit and the above allegation. Per the house rules and admission agreement, clients should use the designated smoking area, not display open hostility to each other, and use a formal greviance process for resident to resident issues. LPA Observed the offensive smoke a substantial(more than 100 ft) distance from the entry way, and at least 50ft any kind of open window. LPA provided guidance about resolving the conflict interally through the enforcement of house rules. Although the allegation may have happened is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Appeal rights provided, an exit interview was conducted, a copy of the report was left with the staff. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 23, 2025 · control 27-AS-20250918124735

Allegation investigated: Facility does not ensure that water is clean and drinkable.

Licensing Program Analyst(LPA) Noel Wolf Petersen, arrived unannounced on 9/23/25 at 9:00 to conduct a complaint investigation, LPA met with the administrator Ashley Sylv and explained the purpose of the visit and the above allegation. LPA asked the facility to check in with thier local water board that services the facility about getting thier water tested for metal/inorganic compound/bactereological elements. A copy of Local water board test results should be sent to the department if they get them. As the water quality falls outside the scope of title 22 this agency has investigated the complaint. 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. The LPA will cross report to sacremento water board. Appeal rights provided. Exit interview conducted, a copy of the report was read and left with the administrator. Unfoundedthe state’s words, verbatim · CDSS document, Sep 23, 2025 · control 27-AS-20250918122016

Allegation investigated: Staff do not ensure the residents’ call buttons are always operational.

On 09/16/2025, Licensing Program Analyst (LPA) Kimberly Varella made an unannounced visit to this facility to open this complaint investigation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator. LPA met with Ashley Sylve the Quality Assurance/Performance Improvement Director (RQAPID)/Designee and a brief interview followed. Ombudsman (O1) was also present during this interview. The ED stated that they have been upgrading and repairing the call alert system in the building since 08/19/25. It went down on 08/19/25, and was back up on 08/22/25, however, the system has not been transmitting alerts as it was designed to and respresentatives from their IT department and the provider of the call system were working on resolving the issue. By 09/17/25, a final determination will be made regarding its ability to be 100% functional. If not, the ED shared that other systems have been evaluated and they will purchase one. This LPA learned that although the repairs for this system have been going on for almost a month, installing a new system might take up to 8 weeks. Substantiated In order to ensure services were provided, resident checks have been increased to once ever 2 hours or once every hour if the resident required it. Staff have been stationed in the hallways so that they may hear residents call for assistance. Bells and whistles have also be purchased to assist residents in alerting staff. In addition, residents have been moved from one side of the building to the other. This was done for multiple reasons: so that repairs and remodels may be completed, to increase the efficiency of the air conditioning units during extreme heat, and to decrease the response time of carestaff. Flyers were put up announcing the move on or about 09/05/25 and the move began on Monday, 09/08/25. LPA and Ombudsman provided technical assistance on the importance of communicating with the residents and their responsible parties regarding resident moves and facility repairs. The ED stated that a formal notice regarding the above information will be mailed out by the close of business on 9/16/25. According to the California Code of Regulations, Title 22, the following regulation was violated: 87303 Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit. This deficiency has been cited on the LIC 9099D page. The ED stated that in the interim, they will relocate the alert system so that it may be physically monitored by staff and functional. The monitor will use walkie-talkies to communicate alerts to carestaff until the system is fully automated and functioning at 100%. No other deficiencies were cited during today's visit, a copy of this report was provided and an exit interview was conducted with Ashley Sylve.the state’s words, verbatim · CDSS document, Sep 16, 2025 · control 27-AS-20250910090018

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1) · Plan of correction due date: Sep 19, 2025

87303 Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1)All facilities licensed for 16 or more... shall have a signal system which shall: The licensee did not meet the above requirement when: Based on observation and interview, the pendant /call alert system has not been functioning properly since 08/20/25. This posed/poses a potential risk to the health safety and personal rights of residents in carethe state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: The ED stated that in the interim, they will relocate the alert system so that it may be physically monitored by staff and functional. The monitor will use walkie-talkies to communicate alerts to carestaff until the system is fully automated and functioning at 100%. The ED will send pictures to Community Care Licensing showing the system in its new location and will provide a schedule of who will be monitoring the system. These photos and schedule will be provided by the close of business on 9/19/25

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: The facility staff are not following infection control guidlines

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with facility administrator Ashley Sylve and explained the purpose of the visit. This investigation consisted of interviews and observation. LPA Moleski interviewed nine staff members (S1-S9) and two residents (R2-R3). In interviews, two staff members (S3-S4) said they had witnessed caregivers not adhering to proper infection control protocol. S3 said that they had seen staff neglecting to wash their hands after caring for a resident and removing their gloves. S3 said this occurs a couple times every week. S4 said they had also witnessed staff neglecting to wash their hands after caring for residents and removing their gloves. S4 said they had also seen caregivers continue to use the same pair of gloves after caring for a resident. In interviews, R2 and R3 both said they do not regularly see staff washing their hands. R2 said they also see regularly see used gloves discarded on the floor. [continued on 9099-C] Substantiated The department has determined the following as it relates to the allegation that facility staff are not following infection control guidelines: Based on interviews, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Section 87470(a)(1)(B)(5). An exit interview was held with Sylve. A copy of this report and appeal rights were left with Sylve.the state’s words, verbatim · CDSS document, Sep 15, 2025 · control 27-AS-20250131105732

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(a)(1)(B)(5) · Plan of correction due date: Sep 26, 2025

" (B) Hand hygiene shall be conducted as follows: ... 5. Immediately before putting gloves on and immediately after removing gloves." This requirement was not met as evidenced by: Based on interviews, caregivers do not consistently wash their hands after removing their gloves, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: Licensee agrees to conduct staff training regarding hand hygiene by POC due date, and to provide LPA Moleski with a training sign-in sheet after completion. vincent.moleski@dss.ca.gov

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff are mismanaging resident's medications.

On 08/13/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. LPA identified herself upon arrival, stated the purpose of the visit and asked to speak with the Designated Facility Administrator/Executive Director. LPA met with Interim Director, Marlene Bremer and a brief interview followed. Regarding the allegation: Staff are mismanging resident's medications. This LPA reviewed the Electronic Medication Record (EMAR) for R1 from 03/01/25 - 05/04/25. The corporate regional nurse for this facility reviewed the symbols on the EMAR with this LPA. This PA observed an error on 04/13/25. There was a symbl logged for two of the the 5:00 PM medications passes (M1 and M2) that this LPA was told meant that the medication was packed up for the family to take with the resident when the resident left the building. However, there was another medication pass at 8:00 PM where it was indicated by a symbol, that another medication (M3) was not given becasue the resident was out of the building. Substantiated The medication was not packed and sent out with the 5:00 PM medications. LPA requested the "Resident Leaves Report" which indicated that the resident left the building at 2:00 PM and returned at 11:10 PM. Even though the M3 was typically given at 8:00 PM, the doctor's instructions were, "TAKE ONE TABLET BY MOUTH AT BEDTIME." R1 retuned to the facility to go to bed and arrangements should have been made by the medication technician to ensure that R1 got their medication. This deficiency has been cited on the LIC 9099 D page. According to the California Code of Regulations Title 22, no other deficiencies were observed or cited during today's visit, a copy of this report was provided and an exit interview was conducted.the state’s words, verbatim · CDSS document, Aug 13, 2025 · control 27-AS-20250522140000

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a) · Plan of correction due date: Aug 14, 2025

(a) A plan for incidental medical and dental care shall be developed by each facility.... routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The Licensee did not meet the above requirement when: Based on a review of the EMAR, R1 returned to the facility on the evening 4/13/25 and there was no plan in place to ensure that R1 was administered thier bedtime medication. This posed (poses) an immedicate risk to the health, safety and personl rights of residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2025

Plan of correction: The Licensee stated that they will develop a plan so that residents who return after scheduled medication passes will still be administered their medications if it is still appropriate and safe to do so. This plan will be submitted to Community Care Licesning by the close of business on 8/14/25.

Allegation investigated: Room used for behavioral interventions is malodorous.

On 08/06/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to open an investigation into the above allegation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator/Executive Director (ED). The ED was out of the building and there was not a Designee present so Ashley Sylve, the Quality Assurance/Performance Improvement Director (RQAPID)/Designee was called to come to the facility. Another staff member, S5, accompanied this LPA on a walkthrough of the facility while they waited for the Designee to arrive. LPA observed the following during her walkthrough. In the common room of assisted living, 2 residents were seated in front of a snack cart waiting for Bingo that was scheduled later in the morning. LPA observed water stations set up throughout the facility with cups and pitchers of ice water. LPA observed 2 housekeeping carts and staff servicing resident rooms. LPA observed a medication pass being conducted at one resident's room. LPA observed the rear door to the facility leading to the building was propped Substantiated open. LPA closed the door and provided technical assistance to staff regarding the need to keep doors without screens closed to ensure the facility was kept free from insects and pests. When this LPA entered the memory care community, she checked the rear exit and it was not alarmed and the door opened freely to the back parking lot. This deficiency will be cited during a follow-up case management visit. LPA also observed residents' artwork (painted canvases) posted on the walls in the hallways of the community. There were 11 residents in the dining room enjoying a morning snack and 4 residents relaxing on furniture in the adjacent hallway supervised by staff. Upon returning to the assisted living area of the community, LPA observed an unlocked laundry room with detergent present and accessible to residents in care. This deficiency will be cited during the future case management. LPA also observed 10 residents playing Bingo led by the activities assistant. 4 other residents were on an outing to botanical gardens supervised by 2 staff. When LPA returned to the lobby area of the facility, LPA noted that the door to the Medication Room was open and that the keys were in the medication cart and the cart was unlocked. There were no medication technicians in the room at this time. LPA interviewed 3 staff members (S1, S2, and S3) who stated that they were instructed to leave the door open so that residents would be able to find them more readily when they were in the med room and not in the community. LPA reminded them that there was no one present in the room at the time the LPA walked in; the door should have been closed and locked so that all medications were inaccessible to residents in care. This deficiency will be cited in the follow-up case management visit. Regarding the allegation: Room used for behavioral interventions is malodorous. Legacy Oaks launched a program where they utilized staff trained on behavioral intervention techniques to assist and redirect residents having behavioral expressions. Residents from both the assisted living and the memory care communities were brought to room 37 where they could get away from triggers, play a game, watch a movie, and behaviors could be de-escalated. LPA visited room 37 which was designed to be a resident room, and observed the following: The window was open and a fan was seated on the floor on one side of the room and blowing the decorations on the wall opposite. There was a diffuser on the counter. LPA observed shelves with games and activities along with a table in the center of the room surrounded by folding chairs. There was a sofa and other furnishings and decorations. LPA observed that the brown carpet was stained in several places, the largest being in front of the sofa area and another extending toward the kitchenette. LPA also observed that the baseboard molding adjacent to the carpet was warped and falling down in places. By the sink, it was completely detached and on the floor. LPA took pictures for documentation purposes. LPA then observed a small bookcase slightly in front of the bathroom door. LPA and a staff person moved the bookcase and this LPA entered the bathroom. LPA observed a broken toilet. The tank had been removed and was in the bathtub. The toilet had dirty brown standing water and toilet paper in it. The vanity was missing the door to the cabinet under the sink and Clorox and other toxic cleaning supplies were observed underneath. The tub/shower unit also had a metal shelving unit in it along with 2 buckets. One of the buckets approximately (3-5 gallons) had standing water in it. LPA took pictures for documentation purposes. A staff member, S1 walked in while this LPA was recording observations. LPA interviewed S1 and asked about the condition of the room. S1 stated they were told the room smelled badly because of the carpet and that was why they were constantly cleaning and brought in the air diffuser. LPA observed that her own eyes were irritated upon entering the room. When Designee Ashley Sylve arrived, LPA requested that the diffuser and fan be shut off and the window closed to see if she could assess what the room smelled like without them. LPA returned later with Sylve and found the room to be malodorous. LPA also observed that maintenance had begun removing all the furniture. Sylve stated that the room was being emptied out in preparation for maintenance to conduct all necessary repairs. While the room was used for behavioral interventions, it was not being used for the purpose that was stated in the facility's plan of operation and facility sketch. This violation will be cited in the follow-up case management visit along with the others motioned previously. Sylve stated they would conduct their Residential Habitation (RH) program in the activities rooms going forward. Room 37 room would be prepared for resident occupancy in order to return to compliance. The allegation: Room used for behavioral interventions is malodorous. Based on observations and interviews with S2, S3, and S4, room 37 was found to be malodorous and unsanitary when this LPA observed the stained carpet, baseboard molding in disrepair, and the dirty brown standing water and toilet paper in the broken toilet in the bathroom. Prior to closing this report, this LPA also observed that the Business Office door was open with no staff present, and resident files with confidential financial information were left accessible to anyone walking by. One of the filing cabinet drawers was left open and in plain site. According to the California Code of Regulations, Title 22, due to time constraints, the other deficiencies noted in this report will be cited in a follow-up case management visit. A copy of this report was provided along with APPEAL RIGHTS and and exit interview was conducted.the state’s words, verbatim · CDSS document, Aug 6, 2025 · control 27-AS-20250804095207

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Aug 7, 2025

Maintenance and Operation 87303(a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met as evidenced by: Based on observation and interviews with S1 S2 and S3, room 37 was found to be malodorous and unsanitary when this LPA observed the stained carpet, baseboard molding in disrepair and the dirty standing water in the broken toilet. This posed/poses an immediate risk to the health, safety, and personal rights to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: The Designee stated that the room will emptied by the close of business today 08/06/25 and residents will not have access to it until all repairs have been completed and the room is compliant and ready for resident occupancy.

Allegation investigated: Staff do not ensure resident has clean bedding.

On 07/11/205, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA Lee met with Resident Service Specialist Dej'ja Bracey and explained the purpose of the visit. The purpose of this visit is to deliver a complaint finding for the allegation above. The current census is 89. A brief interview was conducted with Dej'ja. It was alleged that staff do not ensure residents have clean bedding. This investigation consisted of observations, interviews with residents and facility staff as well as records review. During a facility visit on 06/19/025, LPA Lee inspected the facility’s linen room (47) and observed that it contained sufficient supply of clean linens. In addition, LPA Lee inspected 13 residents’ rooms and observed that the sheets, pillows, and blankets in each room were clean. Each of the 13 rooms also had a posted laundry and housekeeping schedule specific to the residents. Continued LIC 9099-C Unsubstantiated During today’s visit, LPA Lee inspected an additional 7 residents’ rooms and observed that the residents’ bedding was not dirty. Interviews with 11 residents revealed that 9 residents had no concerns about the cleanliness of their bedding and stated that their bedding is changed at least once a week. Interviews with 3 facility staff members indicated that residents’ bedding are changed one to two times weekly coinciding with their shower schedule and as needed. Record reviews confirmed that bedding changes occurred with residents’ showers. Based on the interviews and evidence gathered during the investigation, LPA was unable to corroborate the allegation. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report was provided to Resident Service Specialist Dej'ja at the end of this visit.the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 27-AS-20250617151648

Allegation investigated: Resident's wallet was stolen while in care. Resident was treated disrespectfully by medication technicians.

On 06/04/25, Licensing Program Analyst, (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of the investigation into the above allegations. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator/ED. The LPA met with Jonathan Aguilar and a brief interview followed. Regarding: "Resident's wallet was stolen while in care." The reporting party, resident (R1) alleged that another resident (R2) stole their wallet. During an interview with R1, R1 stated that R2 had stolen many things from their room including money, cologne, and lighters. R1 told this LPA that R2 was both a "thief and a liar." R1 had obtained assistance from a staff member to generate this complaint (S1). This LPA interviewed S1 for more details regarding these allegations. S1 stated that R1 had misplaced or lost track of things in the past. When R1 told S1 that their money, cologne, and lighters had been stolen, S1 went into their room to assist in locating the missing items. In Unsubstantiated care notes dated 12/02/24, S1 wrote, "R1 stated they had a lighter missing, and I found several brand new lighters as well as old ones. R1 stated that money was missing, and I found multiple one-dollar bills, twenties, and 2 tens. I gave them to R1. R1 mentioned that a bag of change was missing, and I also found that. R1 has a lot of things… and R1 doesn't always know where they are, so I believe everything could have been misplaced." S1 also told this LPA that R1 also located their missing cologne. This LPA also learned during the course of this investigation, that R1 was independent and would utilize their mobility device to go out into the community. The device had pouches strapped to it on both sides to carry personal items. Based on interviews with S1, S5, and S7, combined with this LPA's personal observations on 01/02/25, and today, 06/04/25, R1 frequently left these side pouches opened. S1 suggested that when R1 took the bus to the mall or other places in the community, their wallet might have fallen out or someone might have taken it from the open side pouch. S1 said that on several occasions, they would remind R1 to zipper the pouches closed because S1 would notice that they were bunched up and items would be on the verge of falling out. This LPA also reviewed incident reports pertaining to R2 and there was no previous history of, or suspicion of, theft in their background. There were also no incident reports related to behaviors. This LPA interviewed R2 who stated that they would never take anyone else's property and that they were just glad they had moved into a different room. The Department finds the allegation, "Resident's wallet was stolen while in care," to be UNSUBSTANTIATED. A finding of unsubstantiated means although the allegation may have happened or is valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. Regarding: "Resident was treated disrespectfully by medication technicians." R1 believed that R2 had stolen their personal belongings. When interviewed, R1 told this LPA that anyone who was friends with R2 was also a liar and a thief." S1 stated that R1 felt that staff should be loyal to R1 and if R1 was mad at R2, then staff should also be mad at R2 and not interact with R2." When R1 saw medication technicians (medtechs) administering medications to R2, R1 stated that they became afraid if the medtechs were friends with R2 "they might poison R1." R1 refused to take their medications from certain medtechs. R1 refused a total of 24 doses of prescribed medications on 12/16/24 and 12/23/24. This LPA conducted a review of records for the 2 medtechs in question and there were no disciplinary actions, similar or related to, the above allegation in their personnel files. LPA was provided 3 incident reports for R1. On 12/09/24 "R1 was screaming at staff and residents in the dining room. R1 was upset about something to do with their roommate." The report went on to say that R1 persisted to yell and use foul language and dismissive commentary toward anyone trying to assist them. On 2/14/24, it was reported to Community Care Licensing that R1 was verbally aggressive with other residents and facility staff. The report goes on to relay that the resident stated, "The staff is defending a thief, R2 hates white people, and they will yell at them all R1 wants. The resident threatened the staff member stating R1 would report the staff member for defending a thief and a liar." LPA interviewed a resident council member, R3 and R3 stated that R1 was always yelling and being disruptive. R3 was present in the dining room on 12/15/24 and suggested contacting the local ombudsman for assistance with R1's behaviors. On 12/15/24 the incident report described R1 screaming at residents and staff in the dining room. The LIC 624 quoted R1 as stating, "You keep talking to the thief who stole from me and you should be in jail, you are a Nazi like the rest of them and telling everyone not to trust them." The Department finds the allegation, "Resident was treated disrespectfully by medication technicians." to be UNSUBSTANTIATED. A finding of unsubstantiated means although the allegation may have happened or is valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. A copy of this report was provided along with APPEAL RIGHTS. Exit interview.the state’s words, verbatim · CDSS document, Jun 4, 2025 · control 27-AS-20241223102628

Type of visit: Case Management - Incident

On 05/27/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management investigation regarding an SOC 341 for an incident that occurred on 05/22/25. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator/Executive Director (ED). LPA met with Designee, Marlene Bremer, and a brief meeting followed. LPA requested LIC 308 listing Bremer as the Designee. A resident (R1) in memory care reported to staff that someone had slapped them across the face. The facility self reported to Community Care Licensing and the Ombudsman regarding the allegation. The Ombudsman interviewed the Executive Director regarding the allegation and was told that the facility had launched an internal investigation and was obtaining statements. Ombudsman provided consultation regarding details to be provided on the SOC 341. LPA collected an LIC 500 with staff contact information and requested the following documents for R1: Admissions Agreement Care Plan LIC 602 LIC 624s for the past 6 months Care notes from 3/27/25 - 5/27/25 For S1: Personnel Record Training documentation Schedule for April and May 2025 Any disciplinary notes to their file. Due to time constraints, this LPA will return at a later date to continue with this case management investigation. According to the California Code of Regulations, Title 22 there were no deficiencies cited during today's visit. A copy of this report was provided. Exit interview.the state’s words, verbatim · CDSS document, May 27, 2025

Allegation investigated: Staff did not afford resident privacy.

On 05/14/25 Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to open an investigation into the above allegation. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator. LPA met with Jonathan Aguliar the Designated Facility Administrator/Executive Director (ED). The reporting party alleged that a housekeeper did not identify themselves before entering their room on an unscheduled day to service their room. LPA conducted interviews of the parties involved as well as the ED. There were no witnesses in the hallways, and the resident (R1) was alone in their room. Based on the information obtained, staff did not afford resident privacy was found to be UNSUBSTANTIATED. A finding that the complaint allegation is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. Unsubstantiated While conducting interviews, the ED held a stand-up meeting with the staff and management on duty to re-emphasize the importance of knocking loudly and waiting at the door for a response from the resident prior to using a key to enter their room. LPA reminded the ED that these rooms were the homes of the residents and that an increase in communication, both written and verbal, would help to prevent future complaints. LPA provided technical assistance to the ED regarding the privacy of residents. Although the ED communicated in a Resident Council meeting that new housekeepers/maintenance staff had been hired and were awaiting their background clearances prior to starting work, they were not provided advance written or verbal notice of the exact schedules being changed and did not solicit the input of the residents in care. The ED stated that his primary concern was to ensure that housekeeping services were provided and that standards were being maintained. The ED followed up with a plan to distribute a letter to all residents about the changes thus improving communication. According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. A copy of this report was provided, along with APPEAL RIGHTS. Exit interview.the state’s words, verbatim · CDSS document, May 14, 2025 · control 27-AS-20250512131619

Type of visit: Case Management - Other

On 05/14/2025, Licensing Program Analyst (LPA) Kimberly Viarella made a case management visit to this facility for the purpose of delivering an "Order To Licensee/Facility Of Immediate Exclusion From Facility." LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator/Executive Director (ED) Jonathan Aguilar. LPA served Aguilar the "Order To Licensee/Facility Of Immediate Exclusion From Facility" for staff (S1) for a reason not related to this facility. S1 was not present at the time of the visit. LPA advised that the LIC 500 and Guardian Roster be updated to reflect the removal of S1 from the facility staff roster. The facility understands this is an Immediate Exclusion and has agreed S1 cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services unless otherwise ordered by the Department. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed or cited during today's visit. A copy of this report was provided.the state’s words, verbatim · CDSS document, May 14, 2025

Type of visit: Prelicensing

On 12/11/24, an unannounced prelicensing inspection was conducted by Licensing Program Analyst (LPA) Kimberly Viarella at this facility. The LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator / Executive Director (ED) Ashley Sylve. The two met and a brief interview followed. LPA began the visit by comparing the LIC 500 (the staff roster) with the Guardian roster to ensure that all staff had the proper background clearances to be working in this facility. All were in compliance at the time of this inspection. The LPA and the (ED) then toured the facility. LPA inspected kitchen and found that it had enough non-perishable food items for 7 days and perishable items for 2 days. All were packaged and dated appropriately. LPA observed an increase in the amount and variety of fresh fruits and vegetables since the last visit to this facility and the kitchen manager had purchased more low salt/no salt items. LPA observed that fire extinguishers throughout the facility were last inspected on 03/05/24 and were in compliance at the time of this inspection. During the walkthrough LPA observed 2 housekeeping carts in the hallway with the cleaning supplies locked and inaccessible to residents in care. LPA observed 7 residents in assisted living playing Pokeno being led by a staff member. LPA observed 15 residents in memory care in the dining/activity room watching a holiday movie and being supervised by 2 care staff. The memory care director was also available and a third staff member was on break at the time of this walkthrough. All communal areas were decorated for the winter holidays by staff and residents. LPA visited rooms 34 and 35 and found them to contain all of the required furniture, furnishings and lighting to be in compliance at the time of this inspection. LPA visited the Medication Room and inspected the medication cart. LPA pulled a random sample of 12 prescription medications and verified that none had expired and that pill packs observed were up to date with the medications administered. LPA also reviewed administration and destruction procedures with the ED, along with the procedures for administering PRN medications. LPA also observed a gingerbread decorating/eating activity in the front activity room that included residents from both assisted living and memory care. There were over 20 residents present and 8 staff assisting. LPA toured 2 rooms in assisted living and found them to have the required furniture, furnishings, and lighting to be in compliance at the time of this inspection. Bathrooms contained the required grab bars, toilet paper, bath mats and trash cans. LPA measured the hot water temperature and found it to be 105.1 degrees Fahrenheit and in compliance. LPA conducted an inspection of the exterior of the building. There were two sheds. LPA requested that they be unlocked and LPA observed supplies for the Activities Department in one shed. The second shed contained mini refrigerators, fans, and tables as well as other maintenance supplies. All screens and gutters were in good repair an there was no debris on the grounds surrounding the facility at the time of this inspection. There was a covered structure designated as a smoking area and a second structure which needed a new covering that would provide shade for non-smokers. The ED stated that they were collecting bids for the repair of the second structure. At the present time the structure is without a covering but it did not present a safety hazard to residents in care. LPA then conducted a file review for 3 residents (R1, R2, and R3) as well as 3 staff (S1, S2, and S3). All files were in compliance at the time of this inspection. According to the California Code of Regulations, Title 22, there were no deficiencies observed or cited during today's visit. The facility passed its inspection and completed Comp III. LPA to notify the Centralized Applications Bureau (CAB) by the close of business today. A copy of this report was provided and an exit interview was conducted.the state’s words, verbatim · CDSS document, Dec 11, 2024