Madonna Gardens

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Executive Director, Larry VanHorn, Continual Administrator's Certification expires 12/01/2026. There are currently 77 residents who reside at this home and there is 9 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. Fire extinguisher is within the safety regulation period. Smoke alarms are tested and are operational. The home has a carbon monoxide detector. Water temperature was tested between 115 degrees and 119 degrees in multiple different resident bedrooms throughout the facility. First Aid kit is on site and complete. Staff 1 does not have required annual dementia training/ or 20 hours required annual training. The facility is not conducting quarterly disaster drills as required. The staff listed as Infection Control lead is no longer employed by the facility. The facility is not following Plan of Operation (annual staff dementia training.) LPA observed antacid medication in Room 122 of memory care resident. LPA observed cleaning spray in room 147. Non- perishable food supply was low. The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing. Exit interview conducted with Executive Director, Larry VanHorn, and copy of report left at facilitythe state’s words, verbatim · CDSS document, Jul 16, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to conduct a Case Management. LPA met with Director of Sales, Megan Silverman, and explained the purpose of today's visit. The facility self reported an incident on documenting on the afternoon of 03/23/2026 it was identified that on 03/22/2026 that the Assisted Living residents did not receive their 5:00pm medication. Staff 1, the Med Tech assigned to Memory Care completed cross over and the medication count for the Assisted Living with the AM shift Assisted Living Med Tech but Staff 1 failed to complete the med pass or report to supervisory staff about the need for assistance. On the afternoon of 03/23/2026 it was identified that on 03/23/2026 that the Memory Care residents did not receive their morning medication. Saff 2, the Med Tech assigned to Assisted Living, completed cross over and the medication count for Memory Care with the Noc shift Med Tech but failed to complete the med pass or escalate the need for assistance past the Manager on Duty. An immediate audit was initiated to identify all affected residents and medications. At this time, there have been no adverse outcomes identified, and all affected residents are being closely monitored. The facility terminated staff involved in the medication error incident, immediately notified all resident families of incident and also of staffing changes. The following deficiencies are being cited Per Title 22 Regulations, exit interview conducted with Director of Sales, Megan Silverman, and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(4) · Plan of correction due date: Apr 9, 2026

87465 Incidental Medical and Dental Care(4) The licensee shall assist residents with self-administered medications as needed.nThe following requirement has not been met as evidenced by: Facility residents did not get their PM medications on 03/22/2026, and 03/23/2026, which poses an immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2026

Plan of correction: Facility staff involved in incident has been terminated, and facility medication techs will be provided with addittional med tech training and submit proof to LPA by POC date of 04/09/2026.

Allegation investigated: Staff did not provide proper diapering assiatnce to resident in care resulting in a rash Staff did shower resient in care Staff did not wash resident's clothing Staff did not safeguard resident's personal items

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on the allegations listed above. LPA met with facility Business Office Director, Brenda Velasquez, and explained the purpose of today's visit. Regarding the allegation that staff did not provide proper diapering assistance to the resident resulting in a rash, LPA conducted interviews with staff and reviewed Resident 1’s records. LPA interviewed staff 1 who reported Resident 1 required assistance with incontinence care and stated staff routinely changed the resident throughout the shift. Staff 1 reported staff would change the resident multiple times per shift due to urinary incontinence. LPA interviewed staff 2 who reported staff have access to Resident 1’s care plans and are informed of all facility residents’ care needs at the beginning of their shifts. Staff 2 stated staff follow residents’ care plans and provide assistance with toileting and hygiene as needed. LPA interviewed staff 3 who reported they were Resident 1’s primary caregiver during PM shifts. Staff 3 reported the resident required assistance with toileting and dressing and stated they routinely checked the resident approximately three to four times per shift. Unsubstantiated Staff 3 reported Resident 1 required at least two brief changes per shift due to urinary incontinence and occasionally required clothing changes when urine leaked through clothing. Staff 3 further stated Resident 1 experienced a period where more frequent incontinent checks were required, during which staff provided additional hygiene care including showers and clothing changes. Staff reported residents are routinely checked by caregivers because many residents are unable to effectively communicate their needs. Staff reported they did not believe any resident sits in urine movements for extended periods and stated staff would change residents when they are observed to be soiled. Based on interviews conducted and records reviewed, there was insufficient evidence to support the allegation that staff failed to provide proper diapering assistance to the resident. Therefore, the allegation is Unsubstantiated. Regarding the allegation that staff did not shower the resident, LPA conducted interviews with facility staff and reviewed the resident’s records. Staff reported residents receive showers according to their care plans and staff assist residents with bathing as needed. Staff reported the Resident 1’s care plan included scheduled showers and staff provided showers in accordance with the resident’s needs. Staff 3 reported Resident 1 occasionally experienced incontinent accidents and during those instances staff would shower the resident and change their clothing to maintain hygiene and prevent skin irritation. Staff reported Resident 1 may have received additional showers when hygiene needs required it. 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. Regarding the allegation that staff failed to wash the residents’ clothing, LPA conducted interviews with facility staff. Staff reported residents have designated laundry schedules and staff complete laundry services for residents according to the facility’s procedures. Staff stated Resident 1’s clothing was washed as needed and clothing was changed when the resident experienced incontinence episodes. Staff 3 reported Resident 1 occasionally required clothing changes due to urinary incontinence and staff would change the resident’s clothing and ensure the clothing was laundered as needed. Based on interviews conducted and records reviewed, there was insufficient evidence to support the allegation that staff failed to wash the residents’ clothing. 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. Regarding the allegation that staff failed to safeguard the resident’s personal belongings, LPA conducted interviews with facility staff. Staff reported Resident 1’s personal belongings are maintained in Resident 1’s rooms and staff assist residents with laundry and clothing changes as needed. Staff did not report any concerns regarding missing personal items belonging to Resident 1. Staff 4 stated the facility did attempt to address Reporting Parties concern by purchasing new items for Resident 1 even though there was not any evidence that items were actually lost. Based on interviews conducted and records reviewed, there was insufficient evidence to support the allegation that staff failed to safeguard the residents personal belongings. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit Interview conducted with Business Office Director, Brenda Velasquez, and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 12, 2026 · control 24-AS-20251222084031

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to conduct a Case Management. LPA met with facility facility nurse Carmen Bodnar, and explained the purpose of today's visit. The facility self reported an incident on 02/12/2026 documenting on 02/07/2026, Resident 1 received Ativan 0.5 mg tablets earlier than the physician’s prescribed administration times. During the 7:00 a.m. to 3:00 p.m. shift, Staff 1 assisted the resident with administration of Ativan 0.5 mg, which was given approximately 3.5 hours earlier than the physician’s order.During the 3:00 p.m. to 11:00 p.m. shift, Staff 2 assisted the resident 1 with administration of Ativan 0.5 mg, which was given approximately 4.5 hours earlier than the physician’s order.The physician’s order indicates Ativan 0.5 mg tablet, take one tablet by mouth three times daily.Staff 3 stated the computer has been updated to not allow the medication to be given earlier. Technical Violation was reviewed, and exit interview conducted with facility Facility Nurse Carmen Bodnar, , and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 12, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with facility Administrator Jennifer Vasquez, Continual Administrator's Certification expires 07/24/2025. Application to renew Jennifer Vasquez's Administrators certificate was received by Community Care licensing Administration Certificate Bureau on 06/17/2025. There are currently 63 residents who reside at this home and there is 3 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA reviewed the facilities Infection control plan, Emergency Disaster plan, Plan of Operation. LPA reviewed a sample of staff and resident files. Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA observed Resident 1's bedroom did not have required sign indicating Oxygen in use. LPA observed several bedroom showers without non slip flooring mat. LPA observed Resident 2 does not have required bedroom furnishings (dresser.) Water temperature in Room 107 measured 123 degrees. Resident 3 and Resident 4 do not current hospice care plans. Resident 5's medication count was off by 2, and Resident 3 was given one extra dose of medication on 07/16/2025. The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing. Exit interview conducted with Administrator Jennifer Vasquez, and copy of report left at facilitythe state’s words, verbatim · CDSS document, Jul 24, 2025

The state marks this report as 8 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff failed to provide safe, healthful and comfortable accommodations to residents.

Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on April 9, 2025 at 11:30 a.m. to investigate the above allegations. LPA met with facility Assisted Living Director, Marufa Tanzin, and explained the purpose for today’s visit. Regarding the allegation Staff failed to provide safe, healthful and comfortable accommodations to residents. Three out of five residents interviewed stated there is a lot of noise in the hallway (rooms 168 to 190) of the facility, including doors closing loudly, and staff speaking loudly to other residents. LPA heard several doors closing causing a loud sound that could be heard throughout the hallway and in residents bedrooms. LPA observed music coming from room 190 that could be heard in the facility hallway. Based on interviews, and observation the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The following deficiencies are being cited Per Title 22 Regulations. Exit interview conducted Assisted Living Director, Marufa Tanzin, and a copy of this report along with appeals rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Apr 9, 2025 · control 24-AS-20250408092424

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a) · Plan of correction due date: Apr 23, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. The following requirements have not been met as evidenced by: Based on interviews conducted, and observation facility residents are being disrupted by doors closing loudly, and staff speaking loudly, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2025

Plan of correction: Facility will make a plan to correct the loud sounds of doors, music, and doors throughout the facility hallways, and submit to LPA by POC date of 04/23/2025.

Type of visit: Case Management - Licensee Initiated

Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced to conduct a Case Management visit. LPA met with Jennifer Vasquez, and explained the purpose of today's visit. LPA Hurt reviewed an Unusual Incident / Injury Report documenting Resident 1 left the facility and was by the stop sign on the corner when facility staff assisted them back to the facility. Staff 1 stated they saw Resident 1 near a water fountain outside the facility on her way towards the sidewalk walking away from the facility. Resident 1 will be reassessed. Resident 1's Physicians report documents they are able to leave the facility unassisted. Facility staff will conduct 2 hour checks on Resident 1 to ensure safety. Facility staff will be 1 on 1 with Resident 1 until they are re assessed as needed. Technical Assistance provided with Administrator on re assessing Resident 1. No deficiencies are being cited Per Title 22 Regulations. Exit interview conducted with facility Administrator Jennifer Vasquez, and a copy of this report along with appeals rights providedthe state’s words, verbatim · CDSS document, Dec 10, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to open a complaint investigation. LPA met with facility staff Heather Resquir, and spoke with Regional Director, Nestor Mendez by phone, and explained the purpose of today's visit. Staff 1 stated they did have hands on medication administration training, and an 8 hour training course provide by the facility nurse. The facility does not have proof of Staff 1's training required before assisting residents with self administering medications inside facility staff file. LPA Hurt provided Technical Assistance provided for staff not having required documentation of training inside staff file. Exit interview conducted with Facility staff Heather Resquir, and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 3, 2024

Allegation investigated: Staff did not prevent a resident from developing a pressure injury while in care. Facility required an unqualified staff to train other staff. Facility did not ensure that staff are being properly trained. Facility administrator did not prevent residents from missing medication doses. Staff are not properly managing residents medications. Facility did not ensure residents medical assessment forms are updated.

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to open a complaint investigation. LPA met with Medication Technician, Vanessa Martinez, and spoke with Regional Director, Nestor Mendez by phone, and explained the purpose of today's visit. Regarding the allegation Staff did not prevent a resident from developing a pressure injury while in care. There is no records provided documenting Resident 1 had a pressure injury while in the facilities care. Based on documentation obtained and reviewed during this investigation by Department of Social Services staff this 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. Continued... Unsubstantiated Continued... Regarding the allegation Facility required an unqualified staff to train other staff. LPA Hurt interviewed two facility medication technicians, both stated they do allow new medication technicians to shadow them as part of the training process. The medication technicians both stated they are instructed during the shadow process not to train as it is only shadowing. The medication technicians stated they do end up answering any questions the newer medication technicians ask, but they are not training new staff. Based on interviews conducted, documentation obtained and reviewed during this investigation by Department of Social Services staff this 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. Regarding the allegation Facility did not ensure that staff are being properly trained. Staff 1 stated they were given a training course by the facility nurse, and hands on training before assisting any residents with medications. Staff 1 stated they also did shadowing of other facility medication technicians. Based on interviews conducted, documentation obtained and reviewed during this investigation by Department of Social Services staff this 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. Regarding the allegation Facility administrator did not prevent residents from missing medication doses. LPA Hurt reviewed three assisted living residents Centrally Stored Medication Record, and Medication Administration Record from the months of February 2024. The records document all three residents were administered their medications. Based on interviews conducted, documentation obtained and reviewed during this investigation by Department of Social Services staff this 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. Continued... Staff are not properly managing residents’ medications. LPA Hurt reviewed three assisted living residents Centrally Stored Medication Record, and Medication Administration Record from the months of February 2024.The facility staff are assisting residents with their medications. Based on interviews conducted, documentation obtained and reviewed during this investigation by Department of Social Services staff this 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. Facility did not ensure residents medical assessment forms are updated. Several facility residents in Assisted Living do not have their Physician's Reports updated annually as is not required. Based on documentation obtained and reviewed during this investigation by Department of Social Services staff this 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 conducted with Nestor Valdez and Vanessa Ramirez, and a copy of this report along with appeals rights provided.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 24-AS-20240207162534

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a) · Plan of correction due date: Sep 27, 2024

87465Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: Resident 1's had ongoing symptoms of a skin condition. Resident 1's Physician recommended they be seen by a dermatologist several timesthe state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Administrator agrees to do In service training in the August health system to remind staff of appointments doctors are seeking for facility residents, and send proof to LPA by POC date of 09/27/2024.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with facility Business Office Manager, Brenda Velasquez, Continual Administrator's Certification for Renee Hamilton expires 11/22/2024. There are currently 56 residents who reside at this home and there is 5 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 110 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA Hurt reviewed 5 staff files, and 5 resident files. Resident 1 does not have hospice care plan on file. Resident 2 has several medications that are not logged in the Centrally Stored Medication Log. There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing. Exit interview conducted with facility Business Office Manager, Brenda Velasquez, and copy of report along with appeals rights left at facility.the state’s words, verbatim · CDSS document, Jun 26, 2024

Allegation investigated: Staff did not give resident medication as prescribed Staff are not following reporting requirements Staff undressed residents in the common area in front of visitors

Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on June 13,2024 at 10:00 a.m. to investigate the above allegations. LPA met with facility Adminstrator Renee Hamilton, and explained the purpose for today’s visit. Regarding the allegation Staff did not give resident medication as prescribed. LPA Hurt observed a physician speaking with Administrator about Resident 1 has not a specific medication for over a month. The physician stated the facility staff has been faxing the wrong number for refills. Based on records reviewed, and observation the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Substantiated Continued.. Regarding the allegation Staff are not following reporting requirements. LPA Hurt reviewed Madonna Gardens facility online file, and there are no reports from the facility for 12/2023. LPA Hurt reviewed facility care notes for Resident 1 , documenting Resident 1 fell and was transported to the local hospital. This incident was not reported to State Licensing. Based on records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Regarding the allegation Staff undressed residents in the common area in front of visitors. LPA Hurt interviewed two facility staff who both stated on 05/18/24 facility Staff 1 requested female Resident 2 to lift the back of her shirt up past her undergarments to conduct a skin check in front of other facility residents, and visitors. Facility staff did not provide skin check sheets from 05/18/24 for review. Based on LPA interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The following deficiencies are being cited Per Title 22 Regulations, and a copy of this report provided. Exit interview conducted with facility Administrator Renee Hamilton, and copy of report provided.the state’s words, verbatim · CDSS document, Jun 13, 2024 · control 24-AS-20240520102606

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: Jun 27, 2024

87211(a)Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. The following requirement has not been met as evidenced by: Facility staff did not report Resident 1's fall and transfer to hospital, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 13, 2024

Plan of correction: Administrator will conduct staff training on Reporting Requirements, and send proof to LPA by POC date of 06/27/24

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jun 27, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. The following requirement has not been met as evidenced by: Staff 1 exposed Resident 2's skin in a facility common area in front of other residents, and visitors. which posesthe state’s words, verbatim · CDSS document, Jun 13, 2024

Plan of correction: Administrator will conduct staff training on Personal rights of residents, and send proof to LPA by POC date of 06/27/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 14, 2024

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. The following requirement has not been met as evidenced by: Resident 1 was not provided prescribed medication for more than a month, which poses an immediate, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 13, 2024

Plan of correction: Administrator will conduct staff training on medication administration, and provide proof to LPA by POC date of 06/14/2024.

Allegation investigated: Staff did not distribute residents' medications as prescribed Staff do not report incidents to appropriate parties

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to open a complaint on the allegations listed above. LPA Hurt met with Facility Administrator Tyler Barnes, and explained the purpose of today's visit. Regarding the allegation Staff 1 did not distribute residents' medications as prescribed.Resident 1 was not given medication on 04/07/24, and 04/08/2024. Medication Administration Records document "med not available." It is not clear why Resident 1 was not given medication as the medication is available in the facility medication cart. Based on LPA interview conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Continued... Substantiated Continued.. Regarding the allegation Staff do not report incidents to appropriate parties. Facility did not notify State Licensing or Resident 1's Responsible Parties of missed mediations on 04/07/24, 04/08/2024. Based on interviews conducted, and facility records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The following Deficiencies are being cited Per Title 22 Regulations. Exit interview conducted with Administrator, Tyler Barnes, and a copy of this report, along with appeals rights provided.the state’s words, verbatim · CDSS document, Apr 10, 2024 · control 24-AS-20240404121645

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 11, 2024

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. The following requirement has not been met as evidenced by: Resident 1 was not given medication on 04/07/2024, and 4/08/2024, which poses an immediate, heatlh, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 10, 2024

Plan of correction: Administrator will conduct training with facility Staff 1 on medication administration, and submit proof to LPA by 04/11/2024 POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(d) · Plan of correction due date: Apr 24, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. The following requirement has not been met as evidenced by: The facility did not report Resident 1's missed medications to State Licensing, or Resident 1's Responsible party, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 10, 2024

Plan of correction: Administrator will conduct training with staff on Reporting Requirements and submit proof to LPA by POC date of 04/24/2024.

Allegation investigated: Staff are mismanaging resident medications

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on a complaint investigation. LPA met with facility Administrator Tyler Barnes and explained the purpose of today's visit. Regarding the allegation staff are mismanaging a residents medications. LPA Hurt reviewed Centrally Stored Medication Logs, Medication Administration Records, and faxes to and from the Physician documenting all changes, and refusals of medications for Resident 1. There is no medications discontinued, or not given to Resident 1 without orders from a Physician. Based on interviews conducted, documentation obtained and reviewed during this investigation by Department of Social Services staff this 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. Unsubstantiated Continued... Regarding the allegation Staff do not inform residents authorized person of incidents occurring between residents. LPA reviewed facility records titled "Care Notes" for Resident 1. The care notes document several incidents of Resident 1 being aggressive with other facility residents. The care notes do not document facility contacted Responsible Party of residents that were involved in altercations with Resident 1. Based on interviews, and records reviewed during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time. The following deficiencies are being cited Per Title 22 Regulations. Exit interview conducted with facility Administrator Tyler Barnes, and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 11, 2023 · control 24-AS-20230602110418

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a) · Plan of correction due date: Oct 12, 2023

87468.1 Personal Rights of Residents in All Facilities.(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1)To be accorded dignity in their personal relationships with staff, residents, and other persons. The following requirement has not been met as evidenced by: Resident 1 has been in several alteractions with other facility residents which poses an immediate, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 11, 2023

Plan of correction: Administrator will have Resident 1 re assesed immediately, and provide 1 on 1 care for Resident 1 to ensure the safety of other resients and submit proof to LPA Hurt by POC date of 10/12/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Oct 25, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. The following requirement has not been met as evidenced by: The facility did not document Responsible parties for several residents being notified after physical altercations Resident 1.the state’s words, verbatim · CDSS document, Oct 11, 2023

Plan of correction: Administrator will conduct training with facility staff on Reporting to Resident Responsible Parties and submit proof to State Licesning by 10/11/2023 POC date.

Allegation investigated: Residents sustained multiple injuries due to staff neglect

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on a complaint investigation. LPA met with facility Administrator Tyler Barnes and explained the purpose of today's visit. Regarding the allegation residents sustained multiple injuries due to staff neglect. LPA Hurt reviewed facility records documenting Resident 1 did have several falls at the facility. There is no evidence any of these falls were caused by neglect of facility staff. Based on interviews conducted, documentation obtained and reviewed during this investigation by Department of Social Services staff this 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 11, 2023 · control 24-AS-20230921084750