Lincoln Glen Assisted Living Center

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Melissa Docog. LPA explained the purpose of the visit. LPA toured the facility inside of the assisted living and memory care unit with ADM which included the Living room, kitchen, dining room, restrooms and residents bedrooms. LPA randomly toured the following bedrooms: 211, 204, 203, 202, 102, 103, 113, 114, 115, 101, 414, 415, 418, 419, 420, 421, 422, 423, 423, 427, 426. LPA tested every delayed egress exit in the memory care unit, which were observed to be functional. There was no obstruction to block the walkways. The staff area of the facility was also inspected. The front yard and backyard were inspected. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured to range from 112-116 degrees F in resident bathrooms. Fire extinguisher was serviced in January 21, 2026. The facility was equipped with smoke and carbon monoxide detectors. Facility sprinkler system was last inspected on July 14, 2026 by CINTAS. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on August 13, 2026. LPA reviewed facility disaster plan, which was last reviewed/updated on September 11, 2026. LPA reviewed facility records for 4 staff and 4 residents. LPA reviewed 4 resident medications and centrally stored medication records. No deficiencies cited during today's visit. This report was reviewed with Administrator Melissa Docog and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Sep 11, 2026

Type of visit: Case Management - Other

Licensing Program Analyst Manuel Monter conducted an unannounced case management to amend a Complaint investigation (26-AS-20260514093441), LIC9099, LIC9099-C issued on June 19, 2026. LPA met with Administrator Melissa Docog explained the purpose of the visit. The complaint investigation closed on June 19, 2026 is being amended and re-opened due to new information provided to the Department. During today's visit, LPA requested ADM sent a copy of the facility program regarding wander guard. No deficiencies cited during todays visit. This Report was reviewed with Administrator Melissa Docog. A signed copy was provided.the state’s words, verbatim · CDSS document, Aug 28, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to follow up on the previous deficiencies and plan of corrections that were cited. LPA met with Brad Mortenson and explained the purpose of the visit. LPA toured the facility inside and out with ADM. During the tour, LPA tested the delayed egress in the memory care unit, labeled south gate. When LPA pressed, the door opened, without activating the sound. ADM activated the delayed egress on by turning the key switch. ADM noted the interior doors that lead to the back patio, where delayed egree "south gate" located, also has an alarm, when the door is opened. ADM Melissa Docog, stated the facility will conduct an all service training regarding the delayed egress. ADM Melissa Docog stated she will submit proof of training to LPA by August 7, 2026. A technical violation was given during todays visit. This report was reviewed with ADM Melissa Docog and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 4, 2026

Allegation investigated: Resident sustained injuries due to lack of supervision

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Acting Director of Health Services Scott Self. On October 1, 2025 the Department received a complaint alleging resident sustained injuries due to lack of supervision. It has been alleged that staff’s neglect/lack of supervision resulted in R1 sustaining injuries on September 28, 2025. On October 6, 2025, the Department received an incident report regarding R1, dated September 28, 2025. The incident report stated, on September 28, 2025, around 4:45pm, R1 was found lying face down on the floor, next to his/her recliner. R1 was noted with bleeding to his/her left temple and top of his/her nose. 911 was called. Page 1 Out of 3. Unsubstantiated On October 3, 2025, LPA Monter conducted the initial complaint investigation visit. LPA attempted to interview resident R1. R1 stated he/she declined to be interviewed. LPA interviewed staff S1-S7. 7 Out of 7 staff interviewed stated R1 needs assistance with transfers from bed/ recliner /wheel chair. 7 Out of 7 staff interviewed stated R1 is a fall risk. 5 Out of 7 staff (S2- S4, S6, S7) interviewed stated they were not working at the facility on September 29, 2025 during the PM shift, when R1 fell. S1 stated on September 28, 2025, around 4pm, R1 requested to be taken to his/her room to sit on his/her recliner. S1 stated he/she assisted R1 to his/her room. S1 stated 15 minutes later, he/she went to assist another resident, who’s room was in the same direction. S1 stated as he/she was passing by R1’s room, he/she did a visual check on R1, who was still seated on his/her recliner. S1 stated when a staff walks by R1’s room, R1’s recliner is within the line of sight of the hallway and stated on September 28, 2025, R1’s room door was open. S1 stated after he/she had finished helping another resident, he/she heard a thud sound. S1 stated he/she entered R1’s bedroom around 4:30pm and saw R1 sitting next to the recliner. S1 stated R1 was assessed by the hospice nurse who advised R1 going to the hospital. S5 stated on September 29, 2025, he/she saw R1 last around 4pm, in the activity area. S5 stated R1 was taken to his/her room by staff S1. S5 stated at around 4:30-4:40pm, was when R1 was found to have fallen by staff S1. S5 stated he/she was in the activity area of the memory care unit when this happened. S5 stated he/she didn’t hear any yells, screams or calls for help. On October 7 and 9, 2025, LPA Monter interviewed staff S8 and S9. S8 stated he/she wasn’t working on September 29, 2025, when R1 had fallen. Page 2 Out of 3. S9 stated when he/she clocked in on September 29, 2025 around 2:00pm, he/she saw R1 seated in the living room. S9 stated while she was working in the med room, some time has passed. S9 stated a resident R2 had called for assistance and went to assist this resident. S9 stated as he/she was headed to R2’s Bedroom, he/she saw that R1 was no longer in the living room. S9 stated R1’s room is in the walkway and as he/she passed R1’s room, he/she saw from the hallway that R1 was seated on his/her recliner. S9 stated after assisting R2, he/she returned to the med room and saw R1, still seated on his/her recliner. S9 stated he/she didn’t check the time and doesn’t know exactly what time he/she saw R1 last. S9 stated when he/she returned to the medroom, he/she was preparing the 5pm medications. S9 stated then one of the new staff informed him/her that R1 had fallen. S9 stated he/she then went to check R1 immediately. S9 stated he/she observed R1 has sustained an injury due to the fall. On October 16, 2025, LPA Monter interviewed Staff Acting Director of Health Services Scott Self, referred to as HS. HS stated R1 is currently a 1 person assist for all ADLs. HS stated R1 can get up on his/her own but has weakness. HS the facility is doing 2 hour checks for R1. HS stated if R1 tries to get up, staff will assist R1 in going to where he/she wants to go. HS stated R1 has a pendant if he/she needs help, but will spend most of his/her day in the living room. HS R1 is considered a fall risk. The Department reviewed R1's Physician's Report dated June 3, 2025. Based on a review of R1’s Physician's Report, R1 has a neurocognitive disorder. R1 requires assistance with repositioning and transferring. The Department reviewed R1's Needs and Services Plan, dated August 30, 2024. R1’s Needs and Services Plan states that R1 needs to be escorted back to room after activity as needed. Remind resident to ask for assistance when the need for toileting comes. Assist with lowering and raising of clothing. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 3 Out of 3.the state’s words, verbatim · CDSS document, Oct 16, 2025 · control 26-AS-20251001111956

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of a complaint investigation 26-AS-20251001111956. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA is also following up on an incident report received on 10/16/2025. LPA met with Acting Director of Health Services Scott Self Wile investigating the complaint 26-AS-20251001111956, regarding R1, LPA noted issues in resident R1's Care plan. The Department reviewed resident R1’s Progress notes. Progress note dated August 7, 2025 states around 2:30pm, R1 had an unwitnessed fall in his/her bathroom. R1 claimed he/she slipped when trying to use his/her toilet. R1 was able to move all extremities without pain, no complaints of pain, no visible bruises. Progress note dated September 27, 2025, R1 had an unwitnessed fall around 1:40pm. Staff brought resident to his/her room to rest on recliner, then 10 minutes later, a thud was heard. Staff checked on R1 and found him/her next to recliner. Resident was assisted, and no injuries noted. On October 6, 2025, the Department received an incident report regarding R1, dated September 27, 2025. The incident report stated, on September 27, 2025, around 1:40pm, R1 was found sitting on the floor next to his/her chair. R1 stated he/she lost his/her balance and fell. Hospice noticed a small lump on the right side of head. R1 denies pain. R1’s POA was notified and stated he/she didn’t want R1 to be sent to the hospital. Based on a review of R1’s Physician's Report, dated June 3, 2025, R1 has a neurocognitive disorder. R1 requires assistance with repositioning and transferring. The Department reviewed R1’s Needs and Services Plan, Dated August 30, 2024. The Care plan states R1 needs to be escorted back to room after activity as needed. Remind resident to ask for assistance when the need for toileting comes. Assist with lowering and raising of clothing. Based on a review, this care plan was not updated to address R1's requiring assistance with transferring and does not detail a plan to address R1's recent falls prior to September 28, 2025. Incident Report October 11, 2025 On October 16, 2025, the Department received an incident report regarding resident R2. The incident report stated, on October 11, 2025, at 9:00pm, the family of R2 brought a new prescription, medication M1. Family did not inform medtech they had already given dose to resident when they arrived. Med tech started the medication and resident was given a double dose within an hour. On October 16, 2025, LPA interviewed Acting Director of Health Services Scott Self, (HS). HS stated the medtech did not follow procedures when receiving a new medication. HS stated the medtech did follow facility procedures, and did not do a physical count of the medication that just arrived, before administering the medication. HS stated they are doing an in-service today regarding medication administration guidelines and receiving medication administration. Based on a review of R2's physician's report, dated, March 13, 2025, R2 cannot store or administer his/her own medications. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Acting Director of Health Services Scott Self and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 16, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 23, 2025

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 investigation, the facility administered an additional dose of M1. Medtech did follow facility procedures, and didn't do a physical count of the medication that just arrived. This poses a potential health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 16, 2025

Plan of correction: HS stated they are doing an in-service today regarding medication administration guidelines and receiving medication administration. HS stated he will send LPA documenation this training has taken place. HS stated he will send a copy to LPA by POC due date October 23, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Oct 23, 2025

87463 Reappraisals (a) The pre-admission appraisal,... shall be updated in writing as frequently as necessary... to note significant changes in condition... to keep the appraisal accurate... This requirement was not met as evidenced by; Based on record review, R1's Needs and Services plan was not updated to address R1's falls that occured on 8/7/25 and 9/27/25, and how the facility will address this need. This poses a potential health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 16, 2025

Plan of correction: HS stated on September 28, 2025, R1's care plan was updated to address R1's falls. HS stated he will send a letter of understanding regarding the regulation. HS stated he will send a copy to LPA by POC due date October 23, 2025

Type of visit: Case Management - Incident

On October 10, 2025, Licensing Program Analyst Manuel Monter conducted an unannounced Case Management visit to cite a deficiency that was inadvertently not cited on the previous visit. LPA met with Administrator Brad Mortensen. LPA explained the purpose of the visit. On September 26, 2025, the Department conducted an initial visit to investigate the reported incident involving staff S1 physical abuse towards resident (R1), which occurred on October 18, 2024. Staff 1 (S1) employment was terminated October 21, 2024. On October 3, 2025, LPA Monter provided a letter "Order to Licensee/Facility of Immediate Exclusion From Facility" That the department determine that S1 engaged in conduct inimical as a staff in the facility. ADM was informed to remove S1 from any contact with residents and S1 may not be physically present in any facility. ADM agreed and understood. During today's visit, The Department issued citation under HSC 1569.50(a)(3). S1's action towards R1 is considered Conduct inimical to the health, morals, welfare, or safety of residents in care An exit interview was conducted with Administrator Brad Mortensen. Appeal rights was discussed and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 10, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.50(a)(3) · Plan of correction due date: Oct 11, 2025

1569.50 Denial, suspension or revocation of license; ...exclusion from licensee without right to petition for reinstatement (a)(3) Conduct that is inimical to the health, morals, welfare, or safety ... from the facility or the people of the State of California. This requirement was not met as evidenced by; Based on interviews conducted, and evidenced reviewed, staff S1 pushed resident R1, causing R1 to fall. This pose/poses an immediate health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 10, 2025

Plan of correction: Administrator ADM stated that S1's employment was immediately terminated on October 21, 2024 and reported the incident to law enforcement, APS and LTCO. ADM stated that they will provided staff training elder abuse and on warnig signs on unusual incidents that may harm residents. ADM stated he will submit documenation showing this training has taken place, which will include; the staff participating (with their signature), the duration of the training, and the person who conducted the training. ADM stated he will submit the plan of correction to CCLD by POC due date, October 11, 2025.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced Case Management - Incident visit to follow up on the visit conducted on September 26, 2025. LPA met with Administrator Chelsea Chanduloy. On September 25, 2025, the Department received a report which stated on October 18, 2024, staff S1 had pushed R1, one time, causing R1 to fall from his/her walker and onto the ground, resulting in a laceration to R1's head. S2 stated he/she heard a verbal altercation coming from the hallway. S2 stated when he/she went to see what had occurred, he/she saw R1 down on the ground and bleeding from his/her head. S2 stated he/she went to help R1 but S1 pushed S2 to the ground with two hands. The purpose of the visit is to hand deliver an immediate exclusion letter for an individual (S1) who the Department determined engaged in conduct inimical as a staff in the facility. The letter was sealed and handed to Administrator Chelsea Chanduloy No deficiencies cited during todays visit. This report was reviewed with Administrator Chelsea Chanduloy and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 8, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Chelsea Chanduloy. ADM stated the facility currently has 15 residents in memory care and 27 in assisted living. LPA explained the purpose of the visit. LPA toured the facility inside out with ADM which included the Living rooms, kitchen, dining room, restrooms and residents bedrooms in both the assisted living and memory care sections of the facility. LPA toured the following, but not limited bedrooms:215, 110, 102, 108, 416, 405, 410, 405, 415, 414, 409/ There was no obstruction to block the walkways. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 76 degrees F, and hot water temperature was measured to range from 112-116 degrees F in resident bathrooms. Fire extinguishers were serviced on February 7, 2025. The facility was equipped with smoke and carbon monoxide detectors. ADM stated the last time the sprinkler system was inspected on July 25, 2025. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on October 2, 2025. LPA reviewed facility records for 4 staff and 4 residents. LPA reviewed 4 resident medications and centrally stored medication records. No deficiencies cited during today's visit. This report was reviewed with Administrator Chelsea Chanduloy and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Oct 3, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst Manuel Monter conducted an unannounced case management visit in regards to a report Department received regarding R1, which occurred on October 18, 2024. LPA met with Administrator James B Mortensen and explained the purpose of the visit. On September 25, 2025, the Department received a report which stated on October 18, 2024, staff S1 had pushed R1, one time, causing R1 to fall from his/her walker and onto the ground, resulting in a laceration to R1's head. S2 stated he/she heard a verbal altercation coming from the hallway. S2 stated when he/she went to see what had occurred, he/she saw R1 down on the ground and bleeding from his/her head. S2 stated he/she went to help R1 but S1 pushed S2 to the ground with two hands. During the visit, LPA interviewed resident R1, Staff S1 and ADM. LPA requested after visit summary documentation for R1's hospital visit after the altercation. . LPA determined this incident requires further investigation. No Deficiencies cited. This report was reviewed with Administrator James B Mortensen. And a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 26, 2025

Type of visit: POC

On April 24, 2025, LPA Monter conducted a case management POC visit. LPA met with Assisted Living Administrator Chelsea Chanduloy On April 7, 2025, the Department received an incident report (LIC624) regarding a resident (referred as R1) who eloped from the facility. According to the report, on April 5, 2025, around 4pm, resident R1 got out through the side gate. R1 was found by members of St. Christopher’s Church. Members of St. Christopher’s Church called R1’s family member with his/her phone. R1 was brought back to the facility by his/her family who met R1 there. On April 16, 2025, an unannounced Case Management – Incident was conducted. The following deficiencies were cited during visit with a POC due date of April 17, 2025, and were cleared during today’s visit. 87411 Personnel Requirements - General(a) / Type A. Cleared during visit. 87468.1 Personal Rights: (a)(2) / Type A. Cleared during visit. No deficiencies cited during today’s visit. A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 24, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst Manuel Monter conducted an unannounced case management visit-incident regarding an incident report, which stated a resident had eloped from the facility. LPA was also conducting a POC visit LPA met with Memory Care Director (MCD) Evelyn Lax. LPAs explained the purpose of the visit. On April 7, 2025, the Department received an incident report (LIC624) regarding a resident (referred as R1) who eloped from the facility. According to the report, on April 5, 2025, around 4pm, resident R1 got out through the side gate. R1 was found by members of St. Christopher’s Church. Members of St. Christopher’s Church called R1’s family member with his/her phone. R1 was brought back to the facility by his/her family who met R1 there. On April 7 and April 10, 2025, LPA Monter interviewed ADM James Mortensen and Staff S1. ADM and S1 stated R1 doesn't have propensity for wandering. ADM and S1 stated the building R1 was at, has delayed egress. ADM stated the doors make an audible sound and a sound stating the door had been activated, via the walkie talkie. ADM stated R1 exited thru the delayed egress. ADM stated the staff went to investigate. ADM stated staff stated the door alarm was not heard by the staff. ADM stated the staff went and deactivated the door. ADM and S1 stated the staff did not follow the protocol and do a head count after the door alarm activated. ADM and S1 stated the elopement occurred around 4pm. ADM and S1 stated maybe by 5pm R1 was found. ADM stated and S1 stated R1 was found at St. Christopher's Church. (Based on a google maps review of the location R1 was found, R1 was 0.9 miles away from the facility). ADM stated the churchgoers contacted the R1’s family member. ADM and S1 R1’s family member brought R1 back to the facility. Page 1 Out of 2. On April 10, 2025, LPA Monter interview Witness W1. W1 stated the day of the elopement she/he received a phone call from his/her family member, at 5:24pm. W1 stated his/her family member had called him/her to tell her that R1 managed to leave the facility and was found at the St. Christopher's church. W1 stated he/she immediately called the facility to inform them. W1 called R1 who had his/her cell phone and confirmed he/she was at the church. W1 stated he/she went to the church to pick up R1. W1 stated R1 was standing with a churchgoer, who stated R1 attended the entire mass. W1 stated he/she brought R1 back to the facility. Based on a review of R1’s Physician’s Report, dated February 21, 2025, R1 has a neurocognitive disorder. The physician’s report also states R1 has wandering behavior. The Department reviewed R1’ s Needs & Services Plan (ANS) dated March 5, 2025. The ANS states that one of R1’s Needs/Problem is including wandering. Furthermore, the ANS states, R1 will not leave the facility without proper supervision & staff will supervise resident and be aware of whereabouts at all times. As a result, the department issued an immediate civil penalty of $500 for absence of supervision, which resulted in R1 eloping from the facility. An additional Civil Penalty of $250 is being cited for a repeat violation, for the following code section: 87411 Personnel Requirements - General (a), which was cited during a case management visit on April 3, 2025. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. This report was reviewed with Memory Care Director Evelyn Lax and a copy of the report was provided. Appeal Rights was provided. Page 2 Out of 2. END OF REPORT.the state’s words, verbatim · CDSS document, Apr 16, 2025

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

87411 Personnel Requirements - General (a) Facility personnel shall at all times be...competent to provide the services necessary to meet resident needs This requirement was not met as evidenced by Based on investigation, on 04/05/25, R1 had exited the facility via the delayed egress. ADM stated staff went & deactivated the door, but did not do a head count after the alarm activated.This poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 16, 2025

Plan of correction: MCD stated the facility conducted an in-service for staff regarding: Elopment policies and protocols. MCD provided LPA with copy of training conducted on April 10, 2025. MCD provided LPA with documenation during Visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1(a)(2) · Plan of correction due date: Apr 17, 2025

87468.1 Personal Rights: (a)(2) Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on investigation, on 04/05/2025, R1 with a neurocognitive disorder left the memory care unit unassisted and was found 0.9 miles away from the facility, unsupervised. This poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 16, 2025

Plan of correction: MCD stated they have upgraded the alarm system. MCD stated they have also added another alarm system, that will page the radio, which informs staff which door had been activiated. MCD stated they have also change the faciltiy entry procedure and added additonal elopement risk questions to apprisal. MCD stated they have also implemented weekly elopement training, wherin she will activate the delayed egress and note response time. MCD stated the facility also implemented a wander guard as well. MCD provided LPA with documenation during Visit.

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA) Manuel Monter arrived unannounced to conduct a case management visit to follow up on a medication error. LPAs met with Assisted Living Administrator (AL) Chelsea Chanduloy and stated the purpose of the visit. On February 24, 2025 the Department received an Incident Report for a medication error of Resident R1 that occurred on February 22, 2025. The incident report states, resident R1 was accidentally administered the wrong dose of medicine. Instead of Medication M1's 25mg tablet, a medication M2 50 mg tablet was given. On April 3, 2025, LPA interviewed AL. AL stated the medication error only occurred once. AL stated what occurred that day, resident R1 told staff that he/administered two larger tablets instead of two smaller tablets that afternoon. AL stated R1 was administered the wrong dosage. AL stated the very same day R1's doctor/ family was notified. AL stated staff was told observe the resident and check blood pressure. AL stated R1 did not have a change to his her status the same day and the following day. AL stated R1 continued on his/her regular routine, with no issues noted. AL stated staff S1 was given training. AL stated the health services coordinator went over R1's medications with staff S1 to ensure R1's medications are being administered as prescribed. LPA received copies of R1's training's. Page 1 out of 2. Based on a review of R1's physician's report dated, August 7, 2019, R1 cannot administer his/her own medications. A deficiency is being issued during today's visit per California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted with Assisted Living Administrator Chelsea Chanduloy and a copy of this report was provided. Appeal rights were also provided. Page 2 Out of 2.the state’s words, verbatim · CDSS document, Apr 3, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Apr 4, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be...competent to provide the services necessary to meet resident needs This requirement was not met as evidenced by Based on investigation, on 2/22/2025, Staff S1 administered 1 incorrect dose of medication M1 to R1 which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: Administrator stated the facility conducted an in-service for staff S1 on medication training on 2/22/2025. ADM provided documentation of in-service training conducted on 2/22/2025. ADM stated she will also be conducting another hands on training on 4/4/25, and will send LPA documentation showing the training has been completed.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Jame B Mortensen. During the visit, ADM stated the facility has 8 residents in memory care and 30 residents in assisted living. LPA explained the purpose of the visit. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room. LPA toured facility assisted living restrooms and bedrooms, such as, but not limited to rooms: 215, 214, 206, 212, 111, 108, 104, 103, 113, LPA also toured the facility's memory care unit. LPA toured the bedrooms and restrooms, such as, but not limited to rooms: 408, 409, 412, 421,422,424. The staff area of the facility was also inspected. The front and back of the facility was inspected. There was no obstruction to block the walkways. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 79 degrees F, and hot water temperature was measured at 110 - 112 degrees F in both resident bathrooms. Fire extinguisher was serviced in February 12, 2024. The facility's sprinkler system was last checked on August 26, 2024. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on October 2024. LPA reviewed facility records for 5 staff and 5 residents. LPA reviewed 5 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff and 4 residents. No deficiencies cited during today's visit. This report was reviewed with Prospective Administrator Chelsea Chanduloy and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Oct 17, 2024