Leichtag Family Assisted Living Residence

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Health Checks visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Director of Assisted Living, Genesis Franco. President and CEO, Carl Measer was also present. Today's visit was in response to a self-reported incident/death involving Resident #1 (R1). On 08/29/26, R1 sustained a fall, staff called 911 and R1 was transported to the hospital. On 09/08/26, R1 passed away at the hospital. During today’s visit, the facility was briefly toured, welfare check, collected pertinent records and interviewed multiple relevant staff. No deficiencies were observed or cited during today's visit. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to President and CEO, Carl Measer whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Sep 14, 2026

Allegation investigated: Delay in medical care resulting in death.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Assistant Supervisor Alma Sanchez. On 08/01/2025 it was alleged that staff delay in initiating emergency services resulted in Resident 1 (R1)'s passing. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, outside sources, and records review. Interviews were conducted with relevant staff members familiar with the incident in question. Staff interviews revealed that R1 was able to express discomfort and informed they were experiencing pain on the day of incident. Staff informed that assessments were conducted at the facility and R1 was observed to have a change in condition due to their vital signs being out of range. Staff provided R1 with pro re nata (PRN) "as needed" pain medication, an ice pack for comfort, and elevated the situation to management, who advised for R1 to be sent out for assessment. (Continued on LIC9099 p.2) Unsubstantiated (Continued from LIC9099 p.1) Staff and an outside party involved with R1's care left messages for R1's doctor, and the outside party requested to wait for R1's doctor to respond before sending R1 out. R1's doctor subsequently returned the call later in the day and instructed to send R1 to the hospital, which was completed. An interview was conducted with an outside source (OS1) familiar with R1's care and the incident in question. OS1 corroborated that R1 experienced a change in condition the day in question. OS1 informed that they observed R1 to be in severe pain at the facility and R1's physician instructed for R1 to be sent to the hospital. The facility initiated non-emergency transport, which was upgraded to emergency transport due to R1's condition becoming critical. R1 was diagnosed with a systemic infection and an acute kidney issue during the hospital admission. Facility and outside source records relevant to the investigation were reviewed. R1's Physician's Report, dated 05/20/2025, revealed that R1 had diagnoses of cognitive impairment, a kidney condition, as well as multiple disorders of the digestive system. The facility submitted an Unusual Incident/Injury Report regarding the incident in question. The report stated that R1 complained of stomach discomfort, staff conducted an assessment, and elevated the situation to management, who conducted an additional assessment and found R1 to have abdominal pain. R1 was given an ice pack for comfort and was provided pain medication. R1's vital signs were checked and two conversations were had between staff and R1's decision maker regarding R1 being taken to the ER or urgent care; the decision maker requested to wait to hear back from R1's doctor. Upon return call, R1's doctor advised for R1 be sent to the emergency room. Medication Administration History for R1 showed that R1 received pain medication the day of incident, corroborating staff statements. The document noted that the pain medication provided was effective. Facility nursing notes documented that R1's vital signs were checked due to R1 experiencing fatigue with stomach pain; R1 received pain medication per request. The facility advised R1's decision maker that R1's primary care physician would be contacted, and an inquiry was made by the facility whether R1 should be taken to urgent care due to R1's vital signs being out of baseline with low food intake. Facility management advised that R1 should be taken for evaluation. Facility staff left a message for R1's doctor at approximately 1600 hours. R1's decision maker requested to wait for R1's doctor to return the call. The phone call was had with R1's doctor at approximately 1820 hours and it was advised for R1 to be sent to the hospital for evaluation. (Continued on LIC9099 p.3) (Continued from LIC9099 p.2) A discussion was held between staff and R1's decision maker regarding emergency versus non-emergency transport. EMT transportation arrived at 1930 hours and determined that R1 could not be transported due to their vital signs being out of baseline; R1 was then sent to the hospital by paramedics via 911 at 1945 hours. EMS documentation stated that R1's condition had progressively declined throughout the day, and their vitals had become too unstable for safe transport via Basic Life Support (BLS) upon arrival. The call was upgraded to Advanced Life Support (ALS) and R1 was transported via ambulance to the hospital. Hospital records on 06/29/2025 showed that R1 suffered from multiple gastrointestinal comorbidities and was admitted due to an acute kidney condition, low blood pressure, and possible infection. R1 was placed on hospice during this hospital admission and given comfort care measures. An interview was conducted with a medical provider (OS2) familiar with R1's care and the incident in question. OS2 informed that R1's kidney failure had clinically begun a minimum of two to three days prior to presenting at the hospital. The condition resulted in a full-body organ shut down. OS2 informed that R1's passing was not caused by the hours spent waiting to bring R1 to the hospital, and that a change in condition of this type would not be noticeable until the person significantly dropped below baseline. OS2 further informed that patients did not always present immediate signals of infection; that it can sometimes gradually build up before entering the bloodstream. Involved parties and witnesses to the incident provided conflicting statements regarding how/when the decision was made for R1's transportation to the hospital. Interviews showed that R1 received pain medication and an ice pack at the facility for comfort and pain management. No evidence was found to corroborate the claim that staff were explicitly told to have R1 transported to the hospital via emergency transport only, and defied the order. The evidence showed that ultimately, R1's fatal medical chain reaction was set in motion days in advance, and was not due to a delay in medical care. A preponderance of evidence was not found to prove that a delay in care caused R1's passing. Therefore, the allegation is unsubstantiated. An exit interview was conducted with Assistant Supervisor Alma Sanchez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from LIC9099 p.1) Facility and outside records showed that R1 was transported to the hospital via emergency transport on 06/29/2025 at approximately 7:45pm on the day in question. The medication administration record showed that R1 received bedtime medications this same day, which would not have been possible due to R1 not being present at the facility. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred and is therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Assistant Supervisor Alma Sanchez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 17, 2026 · control 08-AS-20250801082715

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Aug 28, 2026

87506(a) Resident Records: The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. Based on interviews and records, Licensee did not ensure that R1's medication record was complete and current. This posed a potential health risk to 1 of 68 persons in care.the state’s words, verbatim · CDSS document, Aug 17, 2026

Plan of correction: Licensee agreed to update the procedures and train medication staff regarding medication administration to include signing for the administration after consumption only. Proof of training will be provided to the Department by POC due date.

Allegation investigated: Staff did not dispense medication to residents as prescribed.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit with Administrator Carl Measer. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. On 6/8/26, it was alleged that staff did not dispense medication to residents as prescribed. Staff interviews indicated that there were no incidents of missed medications or improper dispensing of medications with any residents within the last 3 months. There have not been any reports by residents or outside sources that any medications were not dispensed as prescribed. Unsubstantiated LPA reviewed resident medication records for the month of June 2026 and did not show any medication dispensed improperly. Based on LPA's interviews, observations and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Director of Assisted Living Genesis Franco to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 11, 2026 · control 08-AS-20260606170546

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director Carl Measer, Assisted Living Director (ALD) Mary Fawell, and Memory Care Director (MCD) David Pinto. The facility's license shows a maximum capacity of seventy-seven (77) non-ambulatory residents, nine (9) of which may be bedridden. Bedridden residents may only reside in building E, rooms #1-9. In addition, the facility is approved for a hospice waiver for twenty (20). During today’s inspection there were sixty-seven (67) residents in care. Currently, the facility has five (5) residents receiving hospice services. Note, LPA did step out for lunch from 12:20-1:20pm. LPA and ALD Fawell toured the interior and exterior of the Assisted Living (AL) building, inspecting common areas and a sample of occupied resident rooms. LPA then toured the interior and exterior of the Memory Care (MC) building with MCD Pinto. Both buildings of the facility were clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: One common bathroom sink in the AL building was 108.8F, and two private resident sinks in the MC building read at 108.2F and 107.7F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. [Continued on LIC 809-C] [Continued from LIC 809] The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Both buildings feature satellite kitchens, and the main kitchen/food storage is on a different area of the campus. LPA examined the kitchens and noted food items in those areas were all safely stored. LPA observed dining staff transporting food items from the main kitchens to the satellite ones to prepare for lunch. Cooking, dining equipment, and utensils were present. Knives were noted to be in areas locked and inaccessible to residents. No toxic chemicals or poisons were accessible to clients. LPA and ALD Fawell spoke briefly on medication administration and best practices. Medications in both buildings were labeled, as required, and stored in locked areas. The outdoor courtyard of the AL building does feature a large koi pond with a water-fountain feature, however it is fenced off. Per ALD Fawell, Memory Care residents or other residents at risk if given access to such bodies of water are accompanied by staff if in the area. There is a small water fountain in the yard of the MC building, however it has been adjusted not to feature standing water, mitigating risk for residents. Per both ALD Fawell and MCD Pinto, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire panel in the MC building was last inspected by the local fire department in January 2026. Fire extinguishers were serviced within the last 12 months, also dated for January 2026. Last staff emergency drill was conducted on 12/20/25 and 12/24/25 (different shifts) for the topic of fire. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility, however in the AL building there was no posting of resident personal rights. Per ALD Fawell, they had been taken down to be reframed due to updates to the building months prior. A Technical Violation (TV) was issued and consultation provided regarding required licensing postings. LPA interviewed one (1) staff and two (2) clients, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with ALD Fawell to whom a copy of this report, LIC 9102 (TV), and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Feb 24, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Amy Rodgers Hall conducted an unannounced case management visit to the conduct a health and safety check on residents after a self reported incident on 5/29/2025. LPA discussed the purpose of the visit with Administrator Carl Measer. A health and safety check was conducted to ensure the appropriate overnight relocation of the 35 residents in the assisted living building after an electoral fire in the facility that caused damage in two (2) resident rooms, one of which was vacant. All residents have been safely returned back to the original building as of May 30, 2025, with necessary services and supports in place to ensure continuity of care. The licensee is to notify the department if any structural changes will occur due to fire damage. An exit interview was conducted with Administrator Carl Measer, to whom a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), was provided after the visit.the state’s words, verbatim · CDSS document, May 30, 2025

Allegation investigated: Lack of supervision resulted in residents engaging in inappropriate interactions.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced 10-day visit to initiate a complaint investigation and deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Memory Care Director David Pinto. On 05/23/2025 it was alleged that staff did not prevent residents from engaging in inappropriate interactions. The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff, outside sources, and records review. Staff interviews revealed that Resident 1 (R1) had known behaviors upon admission to the facility of becoming attached to certain people, specifically male residents. Staff interviews further revealed that R1 became attached to Resident 2 (R2), following them around the facility and stating that they were dating. Staff additionally informed that R1's family was made aware and a plan was agreed upon for the residents to be able to interact in common areas, but not privately in rooms. (Continued on LIC9099 p.2) Unsubstantiated (Continued from LIC9099 p.1) Staff informed that R2 did not seek out R1 or initiate interaction with R1, but would accept the attention when given. Staff informed that the residents have never engaged in sexual intercourse, but acknowledged that residents maintain the personal right to do so. Two outside sources were contacted regarding the allegation, both of whom were familiar with the situation and with direct observations regarding interactions between R1 and R2. The outside sources denied that the facility was lacking in supervision between the residents and informed that the residents had not engaged inappropriately or without consent to the interactions. Outside source staff observations were consistent with staff statements regarding R1 initiating interactions with R2 and seeking them around the facility. Outside source interviews did not corroborate the allegation. Review of facility records were consistent with staff statements regarding resident behaviors and R1 becoming fixated on going into R2's room. The documents did not corroborate that staff improperly supervised the residents, or that inappropriate contact occurred between R1 or R2. R1's Physician's Report indicated that R1 exhibited inappropriate behaviors. During an unannounced facility visit LPA conducted a health and safety check for R1 and R2. LPA did not observe the residents together and no health or safety issues were observed. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Memory Care Director David Pinto, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 28, 2025 · control 08-AS-20250523140800

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Memory Care Director David Pinto and Assisted Living Director Mary Fawell to discuss the purpose of the visit. Today's visit is in response to the facility's self-reported incident regarding a resident who claimed they had missing money and jewelry. LPA conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Memory Care Director David Pinto and Assisted Living Director Mary Fawell to discuss the purpose of the visit., who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jan 28, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Memory Care Director David Pinto, Assisted Living Director Mary Fawell. The facility's license shows a maximum capacity of seventy-seven (77) non-ambulatory residents, ages 60 and above, 9 of whom may be bedridden in Building E rooms 1-9. The facility has an approved Hospice Waiver for twenty (20) residents. During today’s inspection there were 54 residents in care. LPA, Memory Care Director David Pinto, and Assisted Living Director Mary Fawell toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. The facility has an outdoor Koi pond which was double-fenced.. Per Memory Care Director David Pinto, Assisted Living Director Mary Fawell, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Memory Care Director David Pinto and Assisted Living Director Mary Fawell, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 28, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Director Mary Fawell, to discuss the purpose of the visit. Today's visit is in response to the self reported incident of a staff member allegedly speaking to a resident in a disrespectful manner. LPA interviewed staff and residents and collected records. A wellness check was completed; no health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Director Mary Fawell, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jul 16, 2024

Allegation investigated: Licensee did not safeguard resident's personal belongings.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced herself and disclosed the purpose of the visit to Nina Haaland, LVN Supervisor. On 1/11/24 it was alleged that Licensee did not safeguard resident's (R1) personal belongings due to a sum of missing money. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, outside sources, and LPA direct observations. Staff interview revealed that upon admission, R1 waived their rights to an itemized inventory of their property. Staff interview further revealed that the Licensee was not made aware that the money existed in R1's possession until after the claim was made that it had been taken. Staff interview revealed that the Licensee provided every resident with a personal safe; R1 had an additional safe installed in their room, to which no staff member had access. Continued on LIC9099-C p.2 Unsubstantiated Continued from LIC9099 p.1 Resident interview did not corroborate the allegation, as R1 confirmed that the Licensee assisted them in taking steps to protect their belongings. Outside source interview revealed that the incident was investigated by the local police agency who determined that the Licensee took steps to protect R1's personal property; no evidence was found to support the allegation. Records review corroborated staff statements regarding R1's waiver to inventory personal property, which was signed on 10/30/23. Records review further revealed that once they were made aware of the missing money, the Licensee made the required notifications within the required timeframes to all agencies and responsible parties. During an unannounced facility visit LPA directly observed both the facility-installed safe and R1's personal safe in their apartment. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Nina Haaland, LVN Supervisor, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 26, 2024 · control 08-AS-20240111090828

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection. LPA Rodgers was granted entry into the facility by Executive Director Carl Measer, after identifying herself and stating the purpose of the inspection. The facility serves 77 non-ambulatory elderly residents, age 60 and above, of which 9 may be bedridden in Building E. rooms 1-9. There is an approved Hospice Waiver for 20 residents LPA was accompanied by Mary Fawell Director of Leichtag Family Assisted Living Residence as well as David Pinto Director of the Katzin Residence, during a tour of the facility, which was conducted inside and out and included a sample of resident units, the dining area, recreation rooms, and satellite kitchen areas. There is a fire signal system in place and the carbon monoxide detectors were operational. The last disaster drill was conducted on December 2023. Exterior and interior passageways were free from obstructions. According to Executive Director Measer, there are no weapons and/or ammunition stored on the premises. Pull cords, restless pads, and sensor lights were present in Building E. Pull cords and remote call buttons were present in Building D. LPA Rodgers observed functionality of signal system. Resident's room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. [Continued on 809-C] [Continued on 809] Facility has a two-day supply of perishable and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closet. Medication rooms are in both building E and D. The medication carts were locked and are located in each medication room. Medications were labeled and kept in compliance with label instructions. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA Rodgers also conducted a review of In-service training procedures. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. An exit interview was conducted and a copy of this report and Licensee/Appeal Rights - LIC 9058 (rev. 01/16) were provided to the Executive Director Measer, whose signature on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jan 16, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced, subsequent Case Management visit to cite a deficiency resulting from an incident self-reported by the licensee. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Chief Operations Officer / Administrator Carl Measer. On 08/11/2023, the CCLD San Diego Regional Office received an SOC341 Report of Suspected Dependent Adult/Elder Abuse from the licensee. Per the SOC341: on 08/09/2023, Resident #1 (R1) told Staff #1 (S1) they wanted to leave their bedroom and sit in the facility’s lobby. [See LIC811 Confidential Names List for a description of person identifiers used in this report.] S1 tried to stop R1 from doing this, placing hands on R1. This did not cause injury, but it caused R1 to become frightened. CCLD’s investigation involved a 09/14/2023 facility tour and welfare check, review of pertinent care and administrative records, and interviews of R1 and relevant staff. During today’s visit, LPA again toured the facility and interviewed additional staff. According to R1’s LIC602 Physician’s Report (dated 12/16/2022): R1 was diagnosed with Mild Cognitive Impairment. Their doctor determined that R1 was not safe to leave the facility unassisted and was “occasionally” confused in the morning, yet R1 remained able to follow instructions and able to communicate their needs. During interview of R1, LPA observed that R1 was vision impaired. R1’s recollection of the incident was coherent, and they were able to be qualified as a credible witness. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Interview of R1, corroborated by multiple staff interviews, showed: During the 08/09/2023 shift, S1 was a contracted home care worker hired by and working under the direction of licensee (rather than working for R1). S1 was therefore acting as one of licensee’s direct care staff. For a brief period of time, S1 repeatedly tried to stop R1 from leaving their bedroom to sit in the facility’s lobby. R1 did not fall and was not injured. R1 said they did not believe S1 was trying to hurt them, but S1’s actions offended and frightened them. CCLD’s investigation did not conclude that S1’s actions towards R1 rose to the level of willful physical abuse. However, a preponderance of evidence does exist to show that S1 violated R1’s personal rights by not allowing R1 to make a choice concerning their daily life at the facility. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Measer, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Dec 8, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(6) · Plan of correction due date: Jan 7, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility.” This requirement was not met, as evidenced by: Based on records and interviews, during the incident, licensee’s staff (S1) did not allow 1 of 59 residents (R1 to make a choice concerning their daily lives in the facility, which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 8, 2023

Plan of correction: Per manager interviews: S1 was suspended from caregiver work in the facility on 08/09/2023 (when the incident came to light). Since then, S1 has not been offered more caregiver work at the facility. Licensee agreed to retrain its larger direct care staff team on Resident’s Personal Rights (as articulated in CCLD form LIC613C-2), and to E-mail a copy of the training sign-in sheet to LPA, by the POC due date.