Magnolia Court

Allegation investigated: Staff do not answer residents calls for assistance timely

**This is an amended report*** Licensing Program Analyst (LPA) Nakagawa conducted an investigation regarding the above allegations and met with Administrator Kristine Hiquiana on 8/19/2026 during an Informal Office meeting to discuss findings. The complaint alleges that Staff do not answer residents calls for assistance timely. The reporting party states that call bells are not answered timely. LPA reviewed a sample of the facility's pendant/call bell system event reports and found that pendants/call bells set off showed elapsed times exceeding a reasonable amount of response time. (Continued on 9099-C) Substantiated (Continued from 9099-A) ****This is an amended report**** Based on LPA’s observation of the dining room staff who help residents with their orders and the facility menu the allegation that Staff do not follow resident’s special food order is Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. The complaint alleges that Staff do not provide timely meals to resident. The complainant states that on multiple occasions, R1 requested food and received none for hours, LPA reviewed R1’s care plan which states that R1 is independent and able to come to the dining room for meals and is able to order meals for room service. LPA reviewed records from food services and found meals delivered to R1's room when R1 did not attend the dining room. Based on LPA’s review of records and interviews conducted the allegation that Staff do not provide timely meals to resident is Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. The complaint alleges that Staff did not administer medication according to physician’s orders and unqualified staff administering resident’s medication. The complainant states on April 9, 2026, R1 was given medication that is prescribed to be given at night. R1 also reported that staff administering medications do not appear to know what medications they are giving, raising concerns about competency and verification processes. LPA reviewed the Medication Administration Records (MAR) for the date in question. According to the MAR the medication in question was administered in the evening by Staff. In addition, reporting party stated that R1 reported that staff administering medications do not appear to know what medications they are giving. LPA reviewed the training records for staff members administering medications and all had received the required training as per regulation. Based on the MAR, the centrally stored medication record of prescriptions ordered by R1’s physicians and the training records of medication technicians the allegations that Staff did not administer medication according to physicians’ orders and Unqualified staff are administering residents’ medication are Unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. The complaint alleges that Staff did not ensure there was a skilled professional to meet residents’ diabetes needs resulting in hospitalization. The complainant states that R1 was transported to the hospital due to in increased blood glucose level after not receiving medication per physician’s order. LPA reviewed facility records and found that R1 did receive testing and medications as prescribed. Based on interviews and a review of medication records, the allegation that Staff did not ensure a skilled professional to meet residents’ diabetes needs resulting in hospitalization is Unsubstantiated. (Continued from 9099) The records reviewed by LPA indicate that calls for assistance are answered in an average of 6 – 7 minutes but there are also a substantial number of calls that are going unanswered for up to an hour or more, which is not timely or safe for residents requiring assistance. Based on LPA’s observations, interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D.”) Deficiencies cited from the California Code of Regulations, Title 22 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. (Continued on 9099-A)the state’s words, verbatim · CDSS document, Aug 19, 2026 · control 21-AS-20260414110307

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(i)(1)(2) · Plan of correction due date: Aug 20, 2026

87303(i)(1)(2)Maintenance and Operation. Facilities licensed for 16 or more and/or facilities that have separate floors or buildings shall have a signal system which meets specified requirements. Facility has an emergency call bell system set up for residents to use as needed and/or in an emergency.This requirement is not met as evidenced by: Based on investigation, file reviews, interviews, Licensee failed to ensure facility staff are responding to pendants/call bells in a timely manner. LPA reviewed the facility's emergency alarm pendant/call bell system event report and found multiple instances of responses tocall bells taking an hour or more. This is an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 19, 2026

Plan of correction: POC: LIcensee/Administrator to ensure that all required facility staff are trained on the emergency call bell alarm system and are following facility's policy and procedures and ensuring a timely response in answering resident's emergency alarms and ensuring they are meeting resident's needs in a timely manner-ensuring that resident's needs, health and safety are being addressed appropriately and within regulations. Submit plan of correction regarding ensuring facility's policy of the emergency call bell system used by residents and written plan of future compliance. Submit future compliance plan no later than 8/20/2026. Proof of completed plan of correction by 8/27/2026.

Type of visit: Office

On 08/19/2026, an informal office meeting was conducted in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager (LPM), Kimberley Mota, Licensing Program Analyst, (LPA) Jill Nakagawa, Administrator Kristine Hiquiana. The following joined the meeting virtually: Mindy Melendez, Vice President of Operations The purpose of the informal office meeting was to discuss areas of non-compliance and observed Community Care Licensing (CCL) concerns of the operation, including substantiated complaints received by the Department. The Administrator was informed that this informal meeting is a part of the Administrative Action process and that further and/or repeat citations may result in a formal Non-Compliance Plan. Items addressed in today's meeting include but are not limited to the following areas of concern: Ongoing medication management issues, despite ongoing training Elopements from Memory Care Unit Inadequate care and supervision: multiple complaints regarding call bells not being answered in a timely manner. Technical Support Provider (TSP) assistance was offered to Licensees during this meeting. Administrator stated that there is ongoing training and management will continue to re-evaluate and assess protocols for medications and pendant call light concerns. TSP will be considered.the state’s words, verbatim · CDSS document, Aug 19, 2026

Type of visit: Case Management - Incident

At approximately 2:45 PM, Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a Case Management - Incident Visit and met with Office Manager Jennifer Roldan. The purpose of the visit was to follow up on a self-reported incident that was received by Community Care Licensing (CCL) on 07/21/2026 . LPA Nakagawa received a report regarding an incident that occurred on 07/13/2026. Facility also self-reported the incident to Vacaville Police. The incident report states that staff was assisting Resident (R1) when R1 asked staff if they would like to see their gun. (R1 had just recently moved in and gun was not in the inventory; apparently brought later by a friend.) Staff notified the police department, who came and inspected the gun. The gun was secured and removed from the facility without incident. No deficiencies were found at the time of inspection. No citations issued. Exit interview conducted with Business Office Manager and a copy of this report along with LIC811 (Confidential Names) was provided.the state’s words, verbatim · CDSS document, Jul 28, 2026

Allegation investigated: Staff do not provide adequate supervision resulting in resident eloping.

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegation. LPA met with Administrator Kristine Hiquiana. The complaint alleges that Staff do not provide adequate supervision resulting in resident eloping. The complainant states that on June 12, 2026, resident R1 eloped from the facility at approximately 5:30 AM using the delayed egress door by their room in the memory care unit. R1 was spotted by staff and followed while off property until police were able to come and assist R1, who was uncooperative and combative, back safely to the facility. R1 was assessed and found to have no injuries. (Continued on 9099-C) Substantiated (Continued from 9099) LPA reviewed records which included the facility's internal investigation forms, incident report, and staff accounts which included a statement from care staff who admitted to falling asleep. A review of R1’s Physician’s Report (LIC602) indicates R1 is unable to leave the facility unassisted. (Deficiency cited). Based on interviews, statements received, records reviewed and LPA's observations, the preponderance of evidence standard has been met. Therefore, the above allegation that Lack of Supervision resulting in Elopement is SUBSTANTIATED. (Deficiency cited.) Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and/or the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. An immediate civil penalty is being issued in the amount of $500 per Health and Safety Code 1568.0822(C)(3) Absence of Supervision. An additional $500 is being issued for arepeat violation within a 12-month period.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 21-AS-20260624081450

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jun 30, 2026

Personnel Requirements – General 87411(a) –Personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement was not met as evidenced by: Based on interviews and file review, facility did not provide supervision to R1 resulting in an elopement. The absence/lack of supervision is an immediate risk to the Health, Safety and Rights of residents in care.the state’s words, verbatim · CDSS document, Jun 30, 2026

Plan of correction: A $500 immediate civil penalty was assessed, and a $500 penalty for a repeat violation (7/17/2025). Licensee/Administrator to submit in-service retraining to all staff on elopement protocols.

Allegation investigated: Staff not administering medications in a timely manner.

On 06/02/2026, Licensing Program Analyst (LPA)Nakagawa and Licensing Program Manager (LPM) Mota arrived unannounced to continue a complaint investigation regarding the above allegations and met with Administrator Kristine Hiquiana to discuss findings. The complaint states that Staff are not administering resident's medication in a timely manner. The reporting party stated that resident R1 did not receive required medications and treatments as required per physician's orders. Per LPA's and LPM's review of Medication Administration Record (MAR) R1 had a missed dose on 2/18/2026. (Continued on 9099-C) Substantiated (Continued from 9099) Based on the MAR the allegation that staff did not administer resident’s medication in a timely manner is is Substantiated. Deficiency cited. (See 9099-D). Deficiencies cited from the California Code of Regulations, Title 22 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. (Continued from 9099-A) In addition, there was no evidence of diaper rash or redness due to improper placement of diaper or a developing rash or that R1 was left in soiled diapers as documented in records. Prior to admission R1 did have a diagnosis of breathing issues, as documented in outside records. There is no indication that R1 sustained any new symptoms while at the facility. Therefore the allegations that Staff were not following residents care plan and Staff left resident in soiled diaper for a period of time are UNSUBSTANTIATED. Although the allegations may have occurred there is not a preponderance of evidence therefore the allegations are unsubstantiated. The complaint alleges that Unqualified staff administering residents medication. Review of staff training records documents that S1 had received the required hours of training per Health and Safety Code 1569.69 therefore the allegation that Unqualified staff were administering residents' medication is UNSUBSTANTIATED. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Jun 2, 2026 · control 21-AS-20260303114041

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5)(A) · Plan of correction due date: Jun 2, 2026

87465(a)(5)Incidental Medical and Dental Care: A plan for incidental medical and dental care...The plan shall encourage routine medical and dental care and provide for assistance...with the following:The licensee shall assist residents...(A) Medications usually prescribed for self-administration which have been authorized by the person's physician. This requirement was not met as evidenced by: Based on review of R1's medication administration record (MAR) there was a missed dose on 2/18/26 which is an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 2, 2026

Plan of correction: Executive Director will submit a plan by 6/4/2026 to ensure that all medication technicians review the rules for proper procedures in medication administration and will go through a re-training regarding accurate documentation in the MAR, including the reporting process to CCL for missed medications. Training to be completed by 6/15/2026 and reported to LPA upon completion.

Allegation investigated: Staff did not provide resident's records to responsible person

On 06/02/2026, Licensing Program Analyst (LPA) Nakagawa and Licensing Program Manager (LPM) Mota arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegation. LPA and LPM met with Kristine Hiquiana, current Administrator (who was not in place at the time of incident) to discuss findings. The complaint alleges that Staff did not provide resident's (R1) records to responsible person. It is alleged that responsible parties were not provided the Incident Report for 10/27/2024. A review of the Incident Report submitted to the Dept. does not indicate that staff provided a copy to the responsible parties therefore the allegation that Staff did not provide resident's records to responsible person is substantiated. (See 9099-D).the state’s words, verbatim · CDSS document, Jun 2, 2026 · control 21-AS-20260527160543

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jun 2, 2026

87211Reporting 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.This requirement was not met as evidenced by: Based on review of the Incident Report of 10/27/2024 the report was not provided to responsible parties as required per regulation.the state’s words, verbatim · CDSS document, Jun 2, 2026

Plan of correction: Licensee to submit copy of Incident Report of 10/27/2024 to responsible parties of R1 within 5 days of receipt.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA)Nakagawa arrived unannounced at approximately 10:40 AM on 04/24/2026 to conduct a case management visit and met with Administrator Kristine Hiquiana. LPA requested documents and conducted interviews regarding incident which occurred 12/27/2025, to establish that resident (R1) sustained no falls/injuries at the facility during residency from 12/22/2025 through 12/27/2025. LPA reviewed report and left copy with Administrator Kristine Hiquiana.the state’s words, verbatim · CDSS document, Apr 24, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a 1-Year Annual Inspection. LPA was welcomed by receptionist and asked to sign the visitor's book. LPA met with Kristine Hiquiana, Executive Director. There were 92 residents in care at the time of inspection. The facility provides both assisted living and memory care. LPA requested personnel and resident records for review. LPA found 3 of 3 resident records and 5 of 5 personnel records well-organized and complete. LPA then toured facility with Resident Services Director, Elizabeth Gomez. 6 resident rooms in Memory Care and 4 rooms in assisted living were inspected and found to be clean, orderly, and furnished as required by Title 22; bathrooms having required grab bars and non-slip mats. The common areas of memory care were well-lit and staff were interacting with residents. There is a secure area for residents in Memory Care to access an outside walking path or sit outside for visits. An inspection of the Assisted Living residence units found the apartments to be furnished appropriately. Water temperature was within regulation. The ambient temperature of the building was between 72-74 F at the time of inspection. The kitchen was clean and well-stocked with an ample supply of perishable and non-perishable foods, as required per Title 22. LPA inspected a sample of fire extinguishers and found them to be fully charged and last serviced on 07/15/2025. The facility's last fire drill was held on 03/23/2026 for all shifts. Elevators were last inspected on 11/07/2025. Fire Department inspected building 11/13/2025. The Emergency Disaster Plan was last reviewed and updated on 03/01/2026. Continued on 809-C Continued from 809.... Stair chairs were installed at the top of each stairway as required. The medication rooms for Assisted Living and Memory Care use an E-Mar system and had the Centrally Stored Medication List available for review. Medications are live-poured and med carts are used for storage and delivery. Facility has a 30-day supply of medication for residents. Nurses are on site daily to help with medication management. The maintenance department had documentation showing their testing and temperature log for hot water. The facility has many outdoor areas for residents to use. LPA inspected and found them to be free of debris and ready for residents to enjoy. The Activities Department for both Memory Care and Assisted Living provide many enriching activities for residents, including arts and crafts, games, musical performances, Bible Study, Family-Involved celebrations and classes. Administrator's certificate is current. The following documents are requested for submission by 4/15/2026: Current Lease Agreement or Control of Property Proof of Liability Insurance LIC 500 - Personnel Report There were no deficiencies found at the time of inspection. No citations issued.the state’s words, verbatim · CDSS document, Mar 30, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a case management inspection and met with Executive Director (ED) Kristine Soriano/Hiquiana. The purpose of today's inspection was to follow up on self reported incidents submitted to Community Care Licensing (CCL) on 03/24/2026. LPA made observations, conducted interviews and obtained copies of resident records pertaining to medication error. On 03/14/2026 at approximately 0930, S1 was at the medication cart preparing meds for a resident. Resident (R1) approached the medication cart and requested their medications. S1 mistook R1 for the resident they were preparing meds for and handed R1 the other resident's medications. S2 observed the mistake and notified the ED, R1's doctor (PCP), Nursing Consultant and the responsible party immediately. Nursing Consultant advised R1 be monitored for any reactions or change in baseline. R1's vital signs were monitored. R1 had no adverse affects to this incident. On 03/21/2026 S2 was assisting R2, when S2 noticed that R2 had an empty medication cup with the room number of another resident. R2 had received the wrong medications by S1. S2 notified the supervisor on duty, R2's doctor, Nursing Consultant and R2's responsible party. R2 was placed under observation and close monitoring for any reactions. R2 remained at baseline. R2 had no adverse affects to this incident. Continued on 809-C Continued from 809.... LPA discussed re-training and shadowing of medication technicians. Copies of relevant records were obtained by LPA. Deficiencies cited from the California Code of Regulations, Title 22 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.the state’s words, verbatim · CDSS document, Mar 27, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Mar 27, 2026

87465(a)(5)Incidental Medical and Dental Care: A plan for incidental medical and dental care...The plan shall encourage routine medical and dental care and provide for assistance...with the following:The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on self-reported incident reports and interview with Executive Director, S1 gave the wrong medication to resident R1 and R2. This is an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: Executive Director will submit a plan by 3/30/2026 to ensure that all medication technicians review the rules for proper procedures in medication administration and will go through a re-training including shadowing assessment with facility's nurse prior to administering medications independently.

Type of visit: Case Management - Incident

On 1/30/2026, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Case Management Investigation regarding three separate incidents self-reported by the facility. LPA met with Administrator Soriano and conducted interviews with effected residents. Incident 1: Administrator reported the theft/loss of resident's (R1) purse on 1/19/2026. LPA spoke with the Administrator who stated they made a thorough search of R1's apartment and a made police report. R1 later reported that the purse had been found in their apartment. Incident 2: Administrator self-reported an incident on 1/20/2026. According to interview with Administrator, R2 reported to family that on 1/18/2026 a caregiver had told them to shut up and shook them brusquely. Family reported incident to Administrator on 1/19/2026. Administrator began an internal investigation and reported the incident to Community Care Licensing (CCL) on 1/20/2026. LPA interviewed R2 on 1/30/2026. R2 was unable to identify the caregiver. Administrator and Community Care Licensing (CCL) will continue to investigate. Incident 3: Administrator self-reported an incident on 1/30/2026 that was reported by R3 on 1/26/2026. R3 came to Administrator and reported that a sum of money was missing from their wallet. Nothing else was reported stolen. R3 was unable to determine a place or person who may have taken the money, but was certain of the time frame. Administrator is conducting an internal investigation and a police report has been filed. Administrator and Community Care Licensing (CCL) will continue to investigate. No deficiencies were found at the time of the investigation. No citations issued. Exit interview conducted with Administrator.the state’s words, verbatim · CDSS document, Jan 30, 2026

Type of visit: Case Management - Other

At approximately 12:50 PM, Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Kristine Soriano. The purpose of the visit was to follow up on a self-reported incident that was submitted to Community Care Licensing (CCL). LPA Nakagawa received a report on 12/15/2025 reporting an incident that occurred on 12/12/2025. Facility also self-reported the incident to Adult Protective Services. The incident report states that on 12/12/2025, Resident (R1) was being assisted in rest room by staff (S1). R1 stated that S1 sprayed them with room freshener rather than the hygienic skin cleanser while helping them. S1 stated that they were using hygienic skin cleanser, which was stored in close proximity to the air freshener and stated that R1 did not react to contact with the spray and it was only after being cleaned told S1 that the wrong product was used. According to Administrator, when investigating the incident they observed that both sprays were located beside one another in the bathroom. R1 also stated that S1 caused marks to R1's arms while S1 was trying to prevent a fall. Resident Care Coordinator and Administrator checked R1 for skin tears and bruising and found no recent marks. R1's Physician's Report states that R1 has areas of thin skin and skin breakdown. Due to the reported incident and fall R1 was put on frequent checks for safety and fall prevention for 72 hours. LPA found no evidence to corroborate that abuse or neglect occurred. Administrator stated that staff will be trained to communicate with the residents when carrying out their duties. No deficiencies were found at the time of inspection. No citations issued. Exit interview conducted with Administrator and a copy of this report along with LIC811 (Confidential Names) was provided.the state’s words, verbatim · CDSS document, Jan 6, 2026

Allegation investigated: Staff are not ensuring resident is showered

Licensing Program Analyst (LPA) Nakagawa arrived unannounced at the facility to conclude the complaint investigation regarding the above allegation and to deliver findings. LPA met with Administrator Kristine Soriano. The complaint alleges that Staff are not ensuring resident (R1) is showered. The complainant states that since moving into the facility in May 2025, R1 has had a problem with showering and facility has not provided the shower standby assistance agreed to in R1's care plan. LPA reviewed R1's care notes and shower sheets and discovered that R1 was not always the one refusing showering. Continued on 9099-C... Unsubstantiated Continued from 9099.... Records indicate that R2 (R1’s roommate) would refuse a caregiver permission to enter the room to shower R1. R1 has a diagnosis of dementia and R2 is not the Responsible Party (RP) for R1. R1's RP was interviewed by LPA, who stated they are aware of the issue and feel that R1 is getting showers, although not regularly, there has not been any medical concerns. Although the allegation Staff is not ensuring resident is showered may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did nor did not occur, therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 21-AS-20251029092654

Allegation investigated: Staff chemically restrained residents

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to continue an investigation regarding the above allegation and to deliver findings. LPA discussed with Administrator Kristine Soriano. The complaint alleges that Staff chemically restrained residents. The reporting party states that “according to multiple staff members who overheard the exchange, the Executive Director instructed med techs to administer PRN medications to all residents in Memory Care for the purpose of keeping them calm…”. Continued on 9099-C..... Unsubstantiated Continued from 9099.... LPA conducted interviews with medication technicians, LVNs and Care Coordinator who all stated that medications are administered only as prescribed and all PRN dosages are documented. LPA reviewed the medication administration record (MAR) of (8) of (30) memory care residents for the month of August 2025 who receive PRN medications and found no irregularities. LPA’s inspection of the medications and prescriptions found (5) of (8) residents only receive a PRN pain reliever such as Tylenol, (2) of (8) receive another PRN medication for pain, and only (1) resident receives a PRN medication for anxiety. PRN medications must be authorized and given as per prescription and charted. LPA attempted to reach the reporting party for further information but reporting party did not respond. Based on record review and interview with medication technicians, care staff and licensed Vocational Nurses on staff dispensing medications the allegation that Staff chemically restrained residents is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 21-AS-20250902213521

Allegation investigated: Facility staff are billing for services not rendered.

On 10/24/2025,Licensing Program Analyst (LPA)Nakagawa arrived unannounced to complete an investigation and deliver findings regarding the above allegation. LPA met with Jennifer Roldan, Business Office Manager for Kristine Soriano, Administrator to discuss. The complaint alleges that staff are billing for services not rendered. The reporting party RP stated that Resident R1 received a billing increase for an increase in services in mid-July, 2025. The reporting party stated that R1 is not receiving the services being billed and paid for which includes: showers twice a week, incontinence care as required, and regular housekeeping to keep the room sanitary. (Continued on 9099-C) Substantiated Continued from 9099-A There is no evidence of staff taking R1’s supplies and when LPA questioned other residents about missing supplies, 4 of 4 resident questioned stated that they had not found anything missing from their apartments. A resident (R2) did state that a staff member had asked to borrow some supplies once, but staff did ask and replenished the supplies later. R1’s supplies are not numbered or inventoried so there is no evidence to establish any misuse of R1’s incontinence supplies. Based on interviews of staff and residents and the lack of evidence to support that supplies were taken the allegation that Facility staff did not safeguard resident belongings is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation that Facility did not safeguard resident’s belongings is UNSUBSTANTIATED. (Continued from 9099) The RP stated that R1 was found soiled on multiple occasions while visiting and staff needed to be called in to care for R1 and empty the trash. LPA reviewed documents and found that there was an assessment made on 6/6/2025 which states that R1 is a Level 4.This level provides a resident full assistance with bathing and all activities of daily living. Although the resident has the right to refuse services (which R1 did often, according to 4 of 4 staff interviews), the care plan in effect charged for the increased level of care and staff should have documented refusals and informed responsible party. On 8/7/25, LPA went to the room of R1 to conduct an inspection of the unit. LPA inspected R1’s room without R1’s presence and found the room to be neat and tidy but a definite smell of urine. LPA inspected bedroom and found sheets soiled with possible urine. Administrator and staff explained that R1 was not combative but yelled aggressively and repeatedly refused staff entry when staff tried to help. LPA noted that R1 was not in the room so staff could have changed the linens at that time. On 9/4/2025 LPA went to the room of R1 and found R1 in the unit in bed watching television. The room was neatly arranged but the room smelled (of feces). Both of these visits found R1 had not received the care/services that were listed in the service plan: the resident being clean and odor free. Additionally, the task list report dated 8/7/2025 stated that toileting tasks for caregivers, med techs and LVN/LPN will give reminders, and check bed each morning for soiled linens and if soiled change the bed and to report strong urine odors to DRS, LVN, Medtech and monitor for possible urinary tract infection (UTI). These tasks were not completed on the dates of LPA’s inspections. Based on LPA’s observations, and review of documents the allegation that staff are billing for services not rendered is Substantiated. The finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency a civil penalty assessment. Continued on 9099-Dthe state’s words, verbatim · CDSS document, Oct 24, 2025 · control 21-AS-20250804125148

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.657(a) · Plan of correction due date: Oct 24, 2025

Health and Safety Code1569.657provides:(a)For any rate increase due to change in the level of care......detailed explanation. This regulation was not met as evidenced by: Based on LPA's observations and review of records, the Licensee failed to provide the additional services that the new level of care and accompanying charges. This serves as an immediate health & safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 24, 2025

Plan of correction: LIcensee agrees to have staff review the care plan with resident R1's representative and provide a detailed explanation of the additional services to be provided to R1. A date of the care plan meeting to be provided to LPA by 10/27/25.A copy of the Care Plan signed by R1's representative will be submitted to LPA by 11/01/2025.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Nakagawa conducted a case management inspection and met with Kristine Soriano, the new Administrator for the facility. as well as Gina Lapid, Care Coordinator for Memory Care and Jhoanna Tagle-Serrano, the Care Coordinator for Assisted Living. The purpose of the case management was to meet with the new Administrator and discuss reporting guidelines, other areas of concern and open complaint investigations. No deficiencies cited at today's inspection.the state’s words, verbatim · CDSS document, Oct 2, 2025

Allegation investigated: Staff do not ensure adequate supervision is provided to residents in care Staff do not ensure care needs of residents are being met Staff do not ensure medications are dispensed as prescribed Licensee allows unqualified staff to dispense medication

On 7/22/2025 Licensing Program Analyst (LPA) Nakagawa arrived unannounced to continue an investigation and deliver findings regarding the above allegations. LPA met with Administrator Candice Moses and Memory Care Director Gina Lapid. The complaint alleges Staff do not ensure adequate supervision is provided to residents in care. LPA observed that during visits on 3/11/2025 (11AM - 4PM), 4/1/2025 (10AM - 4PM), 4/7/2025 (3:20-4:50 PM), 5/29/2025 (10:25AM - 4:55PM), 7/17/2025 (10AM - 2:45PM) and 7/22/2025 (12:55 - 2:00PM) there appeared to be adequate supervision during the time of visit, with a majority of residents out of their rooms socializing in the common rooms; typically 20-22 of 28 residents on the days observed with one caregiver circulating in the common areas and two caregivers and a med tech providing care and medications to residents in their rooms. Based on LPA's observations and staff schedules the allegation that Staff do not ensure adequate supervision is provided to residents in care is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is unsubstantiated. (Continued on 9099-C) Unsubstantiated (Continued from 9099) The complaint alleges that Staff do not ensure care needs of residents are being met. The complainant states that there are only 2 caregivers assigned. Regulations for CCL do not require a ratio between care staff and residents. LPA reviewed facility records and found 3 care staff and one medtech scheduled to work in the memory care unit for the AM and PM shift. LPA observed the facility on multiple occasions (3/11/25, 4/1/25, 4/7/25,5/29/2025, 7/17/25, 7/22/2025) and found the facility to be clean and the residents to be clean and dressed appropriately. LPA observed lunches being served and activities (manicures, Trivia, Bingo, Uno, Art/Coloring) and found residents to be assisted as needed. LPA reviewed a sample of 5 of 28 residents’ care/service plans and found residents care plans were recently updated to meet the residents’ needs. According to staff (S1), incontinence care is not charted but staff have a schedule to ensure residents are receiving two-hour checks and continence care. In addition, according to statements by staff member (S1) residents who are in their rooms receive additional safety and continence/re-positioning care (like for those receiving hospice services). Based on observation of residents, sampling of resident weight records and resident interviews (4 of 28 residents in Memory Care) the allegation that Staff do not ensure care needs of residents are being met is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is unsubstantiated. The complaint alleges Licensee allows unqualified staff to dispense medication and Staff do not ensure medications are dispensed as prescribed. The complainant states various caregivers are assigned medtech duties who are not qualified and they are dishonest about distribution of meds. LPA reviewed staff training documentation which shows that staff employed as medication technicians receive training and are tested to verify their knowledge. Also, licensed LVNs and RNs are employed to supervise care and administer insulin injections to those residents requiring per physician’s orders. LPA reviewed medication records of residents receiving insulin and found that the insulin was administered per doctor’s instructions by a licensed professional/LVN/RN. (Continued on 9099-C2) (Continued from 9099-C) In addition, Medication Administration Records (MARs) were inspected and found to be completed. LPA performed an inspection of random medications pulled from the medication room in Memory Care and 5 out of 5 were accurate. Based on the review of MARs, medications, training records and inspection of professional licenses the allegation that Licensee allows unqualified staff to dispense medication and Staff do not ensure medications are dispensed as prescribed are unsubstantiated. Although the allegations may have happened there is not a preponderance of evidence to verify the allegations therefore, the allegations that unqualified staff are allowed to dispense medication and Staff do not ensure medications are dispensed as prescribed are unsubstantiated.the state’s words, verbatim · CDSS document, Jul 22, 2025 · control 21-AS-20250407085527

Type of visit: Case Management - Incident

At approximately 10:05 AM, Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Candice Moses and Mindy Melendez, Chief Strategy Officer (CSO). The purpose of the visit was to follow up on self-reported incident that was submitted to Community Care Licensing (CCL). LPA Nakagawa received a call from Administrator on 07/07/2025 to self-report an incident that occurred on 07/06/2025; incident report was filed on 07/09/2025. The report stated that on 07/06/2025, Resident (R1), who has a diagnosis of dementia and is unable to leave facility unassisted, eloped from community sometime before 9:45 PM. Paramedics called the overnight phone asking if the facility had a resident (R1). Staff were unaware of R1’s elopement as no alarms were set off. R1 was identified and paramedics stated they had taken R1 to Vaca Valley emergency room. Administrator, hospice and family were notified. R1 was discharged from hospital the following day. Per R1’s Physician’s Report (LIC602) R1 is diagnosed with Dementia and is unable to leave the facility unassisted. (Deficiency cited) Civil Penalty for $500.00 was issued during today's visit for Zero Tolerance, Absence of Supervision. See LIC809-D for Deficiency. Exit interview conducted with Administrator and CSO and a copy of this report along with LIC811 (Confidential Names) was provided.the state’s words, verbatim · CDSS document, Jul 17, 2025

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

87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by: Based on incident report and interview, facility failed to provide supervision to R1 resulting in an elopement. The absence of supervision is an immediate risk to the Health, Safety and Rights of resident in care.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: Administrator submitted proof of training conducted with Memory Care staff on 7/7/25 to CCL on 7/17/25 re: conducting ongoing in-service training about elopement procedures, and will self-certify that all alarms, delayed egress, and sensors in memory Care are functioning by submitting a check-off list for PM Med. Tech. to complete each evening to ensure lights, sensors and alarms are 100% operational. ****A civil penalty is being assessed for $500.00.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a 1-Year Annual Inspection. LPA was welcomed by receptionist and asked to sign the visitor's book. LPA met with Candice Moses, Administrator. There were 82 residents in care at the time of inspection. The facility provides both assisted living and memory care. LPA requested personnel and resident records for review. LPA found 5 of 5 resident records and 5 of 5 personnel records well-organized and complete. LPA then toured facility with Director of Resident Care and Director of Memory Care. 10 resident rooms were inspected and found to be clean, orderly, and furnished as required by Title 22. The common areas of the Memory Care Unit were well-lit and staff were interacting with residents. There is also a secure area for residents in Memory Care to enjoy a walk or relax outside. Assisted Living apartments were found to be furnished appropriately, with bathrooms having the required grab bars and non-slip mats. Water temperature was within regulation. The ambient temperature of the building was between 72-74 F at the time of inspection. The kitchen was clean and well-stocked with an ample supply of perishable and non-perishable foods, as required per Title 22. Fire alarms had been inspected on 03/24/2025 and found to be operational. The facility conducted fire drills for all three shifts in April, 2025. . Continued on 809-C Continued from 809..... Stair chairs were installed at the top of each stairway as required. The medication rooms for Assisted Living and Memory Care use an E-Mar system and had the Centrally Stored Medication List available for review. Medications are live-poured and med carts are used for storage and delivery. Facility has a 30-day supply of medication for residents. Nurses are on site daily to help with medication management and resident assessment. LPA inspected the facility's outdoor areas and found them to be free of debris and ready for residents to enjoy. Administrator's certificate #7008136740 is current. All required postings were present. The following documents are requested for submission by 6/5/2025: Current Lease Agreement or Control of Property Proof of Liability Insurance Updated Disaster Plan Discussion was had regarding acceptable courses for First Aid/CPR certification. No citations issued.the state’s words, verbatim · CDSS document, May 29, 2025

Allegation investigated: Facility has insufficient food service. Residents are not accorded dignity in their relationship with staff. Staff do not provide activities for all residents.

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an investigation regarding the above allegations on 3/11/2025 and 04/01/2025. LPA Nakagawa met with the Administrator Candice Moses and the Memory Care Coordinator Gina Lapid to discuss. Regarding the allegation Facility has insufficient food service: LPA toured the facility kitchen on 04/01/2025 and found an ample supply of fresh and frozen foods to supply the menu choices. The chef stated that all residents in Assisted Living and Memory Care communities are given the same multiple choices at each meal. A copy of the menus for 03/02/2025 through 04/05/2025 was provided to LPA. LPA was told by staff Memory Care Director Gina Lapid that meal service in Memory Care is brought over from the central kitchen pre-plated and served by care staff. Continued on 9099-C Unsubstantiated Continued from 9099.... These meals are the same as those served in the main dining room, although some are specially prepared as some residents require their food pureed or cut up, others prefer finger foods. Other considerations in serving food in Memory Care include cueing, special utensils or feeding. At the time of inspection three (3) residents require pureed or mechanical soft diets. Residents in the dining area are observed during meals by care staff with assistance in cueing or eating given, as needed. On 03/11/2025 and 04/01/2025 LPA observed lunch service with staff encouraging residents to eat and to offer additional portions. Several residents have records kept on their intake. Residents are weighed each month and weight loss is reported to doctors and responsible parties. Recent weight records uncovered one resident (R1) who was losing weight. Responsible party and doctor were notified, adjustments were made quickly and resident has been steadily gaining weight. According to S2, many residents in Memory Care put on weight due to the attention and oversight they receive throughout the day and especially during meals. Residents in Memory Care are served three snacks a day. Hydration breaks are also given throughout the day by the Medication Technician and the Activities Director. Based on the evidence, the allegation that Facility has insufficient food service is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation Residents are not accorded dignity in their relationship with staff: LPA observed staff/residents interactions on two (2) occasions (03/11/2025 and 04/01/2025) and found no incidents of staff treating residents in an undignified manner. LPA spoke with family members, home health employees and care staff, as well as three (3) residents. Eleven (11) of eleven (11) individuals all agreed that staff treated residents with respect and dignity. Based on the evidence, the allegation that Residents are not accorded dignity in their relationship with staff is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Continued on 9099-C(2) Continued from 9099-C Regarding the allegation Staff do not provide activities for all residents: LPA Nakagawa has made multiple visits to the facility and found activities taking place. The facility has activities personnel for both the Assisted Living (AL) and Memory Care residents and when they are off care staff conduct activities with residents. LPA found posted Activities Calendars (as required by Title 22 Regulations) for both Memory Care and Assisted LIving, including Exercise Classes, Puzzles, Board Games, Walking Club, Manicures, Movie Nights, monthly Birthday Celebrations, Painting and Cooking, and of course, Bingo. On 04/01/2025, at the time of inspection, LPA found 22 of 28 residents taking part in a game of Bingo with staff S1. Three (3) other residents were in a room adjacent to the activity watching TV in the living room. This was primarily the same scenario LPA found on past visits (01/30/2025, 03/11/2025). Staff (S2) stated that residents who refuse/choose not to participate in activities are encouraged to be in proximity to the group so they can passively participate, but residents cannot be forced to participate. At the same time, there were three (3) residents resting in their rooms. Based on the evidence, the allegation that Staff do not provide activities for all residents is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No citations issued.the state’s words, verbatim · CDSS document, Apr 1, 2025 · control 21-AS-20250306150522

Allegation investigated: Residents not provided proper nutritional needs Staff does not ensure residents grooming needs are met Lack of supervision resulting in falls

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to continue an investigation regarding the above allegations. LPA Nakagawa met with the Administrator Candice Moses and the Memory Care Coordinator Gina Lapid to discuss. During the course of the investigation, LPA conducted unannounced inspections on 01/09/2025 and 01/30/2025, made observations, reviewed records, and interviewed staff and others. Due to no contact information, LPA was unable to obtain further information from the reporting party. It is alleged that Residents are not provided proper nutritional needs. LPA toured the facility kitchen on 01/09/2025 and found an ample supply of fresh and frozen foods to supply the menu choices which are provided to all residents: Assisted Living and Memory Care communities. Continued on 9099-C Unsubstantiated Continued from 9099.... Staff (S1) stated that all residents are given multiple choices at each meal. A copy of the menu was provided to LPA. At the time of inspection five (5) residents require pureed or mechanical soft diets but receive the same foods but prepared as ordered by physician. LPA was told by Staff (S2) that meal service in Memory Care is brought over from the central kitchen and served by care staff. Through interviews, LPA was informed that some residents require their food cut up, others prefer finger foods, and some use utensils, some require cueing and others are fed. Residents in the dining area are observed during meals by care staff; several residents have records kept on their intake. Residents are weighed each month and weight loss is reported to doctors and responsible parties. Residents in Memory Care are served three snacks in addition to three meals a day. Hydration breaks are also given throughout the day by the Medication Technician and the Activities Director. Based on the evidence, the allegation that Residents are not provided proper nutritional needs is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. It is alleged that Staff does not ensure residents grooming needs are met. LPA toured the Memory Care community on 01/09/2025 and 01/30/2025. At the time of the inspection on 01/09/2025 LPA observed 15 of 28 residents and 20 of 28 residents on 01/30/2025: some resting in their rooms, some in the Activities Room watching a church service/TV, others in the Dining Room socializing. LPA found them to be physically clean, dressed appropriately in clean clothes, hair combed. Men appeared to be shaven recently. Memory Care requires that residents do not have access to sharp objects and so residents must have nails cut. Although several residents observed had longer nails; nail beds were clean and grooming needs were met. Therefore the allegation that Staff does not ensure residents grooming needs are met is unsubstantiated. Continued on 9099-C2 Continued from 9099-C Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. It is alleged that Lack of supervision resulting in falls. LPA reviewed staffing records and found that there are three care staff and a medication technician scheduled per shift. There are additional personnel during regular working hours including the Activities Director and the Memory Care Resident Care Coordinator (five days per week). Residents are closely supervised in the common areas of the memory care unit and there is a call bell system in the bathrooms of all rooms. Staff (S1) stated that all residents are checked on regularly throughout their shifts. Based on the evidence the allegation Lack of supervision resulting in falls is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No citations issued.the state’s words, verbatim · CDSS document, Jan 30, 2025 · control 21-AS-20250109092615

Allegation investigated: Staff not meeting residents care needs

Licensing Program Analyst (LPA) Nakagawa arrived unannounced and conducted a complaint investigation regarding the allegation listed above. LPA met with Candice Moses, Administrator. The complaint alleges that staff are not meeting resident’s care needs. During the investigation LPA reviewed records, made observations and conducted interviews. LPA's record review found that resident R1 was hospitalized from 7/21/24 – 7/27/24. A review of records during this time did not reveal any concerns regarding R1’s care. On 8/13/2024 R1 was sent to ER and at that time there were concerns raised regarding hygiene care. Continued on 9099-C Unsubstantiated Continued from 9099.... LPA reviewed care notes for R1 and found that staff attempted to give R1 regular continence care, showers, or bed baths and to reposition resident as per doctor’s orders. Care notes indicate that R1 could be combative or refuse care and additional staff was utilized to help facilitate care. Notes from home health reviewed do not show any indications facility failed to meet resident’s care needs. Although the allegation could 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.the state’s words, verbatim · CDSS document, Nov 12, 2024 · control 21-AS-20240813153600

Allegation investigated: Due to a lack of staff, residents are not assisted with feeding

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegation and met with Administrator Candice Moses. The complaint alleges that due to a lack of staff, residents are not assisted with feeding. LPA reviewed documents and conducted interviews which revealed that 2 of 28 residents in memory care, residents R1 and R2, require assistance with feeding. There are additional residents, R3 and R4 who require constant re-direction to eat and/or assistance in cutting their food and receiving proper utensils. Continued on 9099-C Substantiated Continued from 9099..... LPA also observed that residents with dementia are not being supervised when being served meals in their rooms (resident R3) with food not being eaten due to lack of direction and food being served improperly (not cut up into bite size pieces) as residents are not supplied with knives for their safety. Based on LPA’s observations and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation that due to a lack of staff, residents are not assisted with feeding is found to be substantiated is being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Nov 12, 2024 · control 21-AS-20240826150840

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 12, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ... Personal Rights of Residents... following personal rights: (4) To care, supervision, and services that meet... need delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement was not met as evidenced by: :Based on interviews conducted and LPA’s observations of residents being unsupervised during feeding the Licensee failed to ensure that residents were assisted with feeding. This serves as an immediate health & safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 12, 2024

Plan of correction: Administrator to provide CCL with an update LIC-500 showing adequate staffing for all shifts by 11/14/2024 and Administrator to provide in-service training for all caregiving staff to review care and feeding of residents in Dementia Care. Administrator to submit scheduled training date to CCLD by POC date 11/14/2024 and submit completed signed training log to CCLD by POC date 11/21/2024.

Allegation investigated: Staff inappropriately posted residents on personal social media

Licensing Program Analyst Jill Nakagawa arrived unannounced to conduct an investigation and deliver findings regarding the above allegation. LPA met with Administrator Candice Moses . The allegation states that the Staff inappropriately posted residents on personal social media. Based on LPA interviews, review of records, and photos LPA obtained, the investigation has revealed that the Staff S1 violated residents’ personal rights by posting resident photos on Facebook without consent. The preponderance of evidence standard has been met, therefore the allegation that Staff inappropriately posted residents on personal social media is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached 9099-D). Continued on 9099-C Substantiated Continued from 9099..... Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Appeal Rights Given. Exit interview conducted with the Administrator.the state’s words, verbatim · CDSS document, Nov 12, 2024 · control 21-AS-20241106125840

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Nov 12, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations...telephone... use of the Internet, and meetings of resident and family groups. This is evidenced by: Based on LPAs observations of photo including resident posted on internet without consent. This poses a potential health & safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 12, 2024

Plan of correction: Administrator to provide in-service training for all staff to review resident rights and protocols for using residents’ images on social media. Administrator to submit scheduled training date to CCLD by POC date 11/13/2024 and submit completed signed training log to CCLD by POC date 11/20/2024.

Allegation investigated: Facility staff are not allowing resident to have visitor(s)

LPA Nakagawa arrived unannounced to deliver findings regarding the above complaint allegation and met with the new Administrator, Candice Moses. Facility staff are not allowing resident to have visitor(s) – Complaint alleges that facility staff are not allowing resident to receive visitors. Per interviews, it was confirmed that the facility stopped visitation for individuals as directed by a resident’s responsible party. No documentation was provided to allow for this action. Based on interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC 9099D. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Continued on 9099-D Substantiated Continued from 9099-A Per review of Special Incident Report, resident was being assisted to their bed by staff when they suddenly fell resulting in a broken arm. CCL was unable to confirm through interviews or record review that resident sustained multiple injuries due to staff neglect as indicated in the complaint. Facility is not meeting resident's care needs – Complainant alleges multiple instances where resident’s care needs were not met including, but not limited to, facility staff failing to send resident to the doctor when a growth was found on their face which turned out to be skin cancer, resident not being showered and only receiving sponge baths, which contributed to them getting a Urinary Tract Infection (UTI) and that resident was not having their face washed or teeth brushed. Per interview, resident received bed baths while they had broken arm but staff denied bed baths at any other time. CCL was unable to confirm through interviews or record review that staff failed to respond to resident’s care needs as indicated in the complaint. Facility staff handle the resident in a rough manner – Complaint alleges that a staff was observed pulling a resident up by one arm, not allowing them to catch their balance, and then dragging them by their arm to the bathroom to wash them using wet toilet paper with no soap to wash the resident in the bathroom. Interviewed staff denied dragging resident and using wet toilet paper to wash resident. CCL was unable to confirm through interviews or record review that staff handled resident in a rough manor and used toilet paper to wash them as indicated in the complaint. Facility staff are not ensuring resident privacy – Complaint alleges that another resident goes into Resident, R1’s room. Despite R1 expressing that they don’t want them to come in, staff do not ensure that resident does not go into other residents’ rooms. Per interviews, staff attempt to redirect residents and will lock rooms at the request of a resident. CCL was unable to confirm through interviews or record review that staff are not ensuring resident privacy as indicated in the complaint. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.the state’s words, verbatim · CDSS document, Sep 27, 2024 · control 21-AS-20240523083545

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Sep 27, 2024

87468.1(a)(11) 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: (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. Based on record review and interview, the licensee did not comply with the section cited above when they stopped visitation at the direction of the resident’s responsible party which poses an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 27, 2024

Plan of correction: Licensee will ensure that residents rights are maintained. Licensee will submit a self-certification (LIC9098) that all staff had been notified about regulation by POC due date of 09/30/2024.

Allegation investigated: Staff did not follow protocols to prevent the spread of illness.

LPA Nakagawa arrived unannounced to deliver findings regarding the above complaint allegation and met with Candice Moses, the newly appointed Administrator. Staff did not follow protocols to prevent the spread of illness – Complaint alleges that covid positive cases were not being reported and positive residents were walking around. Per interview, facility reported a Covid outbreak on 7/7//2024 to the local public health department and created a Special Incident Report for CCL on 7/8/2024. CCL received the report on 7/9/2024. Per the Special Incident Report, a third resident tested positive on 7/7/2024, which prompted the facility to report the Covid outbreak, per local public health requirements. Per interview, Covid positive residents isolated well, except one Memory Care resident who had to be redirected frequently. When the resident refused to isolate, facility staff asked them to mask and attempted to provide distance between resident and Covid negative residents who were not required to isolate. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Nothe state’s words, verbatim · CDSS document, Sep 27, 2024 · control 21-AS-20240708160837

Allegation investigated: Staff did not provide adequate supervision to resident in care

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to deliver findings regarding the above complaint allegation and met with Mike Carpenter, Interim Administrator. Staff did not provide adequate supervision to resident in care – Complaint alleges that a staff brought their family member to the facility allowing them to go into resident rooms without permission and “rummage” through the rooms. CCL staff conducted multiple interviews but were unable to corroborate that this event happened. Although the allegation that Staff did not provide adequate supervision to resident in care may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Nothe state’s words, verbatim · CDSS document, Sep 6, 2024 · control 21-AS-20240610105634

Type of visit: Case Management - Other

On 08/27/2024, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced for the purpose of a Case Management. LPA inspected the facility to verify an individual who was issued an exclusion was not on the premises. Gina Lapid, Memory Care Director contacted Jennifer Roldan , Business Office Manager, who was able to verify that no such person was not working at the facility or on site. No deficiencies cited.the state’s words, verbatim · CDSS document, Aug 27, 2024

Allegation investigated: Staff does not provide adequate supervision resulting in residents leaving facility

On 7/9/2024, Licensing Program Analysts (LPA’s) Tobola and Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and were greeted by Acting Administrator, Mike Chatman. LPA’s toured the facility, interviewed staff and outside parties, reviewed resident and facility records and made observations during the course of the investigation. Complaint alleges staff does not provide adequate supervision resuliting in residents leaving facility. Based upon review of facility incdient reports it was found that on the evening of 5/22/2024, resident (R1) had been found out in the community unassisted. Based upon a review of R1's Physicain's Report it is indicated that R1 is diagnosed with dementia and resides in the memory care unit. In addition, review of the Preplacement Appraisal indicates that R1 required special observation/night supervision due to confusion, forgetfullness and wandering. Lastly, review indicated contracdicting information on R1's physician's report regarding R1's capabilities. Facility was requested to updated R1's documentation. Continued onto LIC9099-C Substantiated Complaint alleges due to lack of supervision, resident on resident assaults occur. Based upon a review of facility records and incident reports, it was found it was found that on 5/21/2024 R2 had been reported to demonstrate physically aggressive altercation with resident R3. Based upon a review of facility and resident medical records it was found that the facility notified R2's physician of the incident and implemented a medication change and increased redirection based on observed aggression. Record review also indicated that on 5/23/2024, R2 was observed by staff, attempting to choke resident (R4) but with staff successfully being able to redirect R2. This also indicates facility is implementing care intervention. Lastly, resident records indicate that the facility had contacted R2's family to discuss increased supervision. Due to a lack of corroborating information the allegation is found to be unsubstantiated. Allegations, staff does not provide adequate information regarding resident to responsible party and due to lack of supervision, resident on resident assaults occur are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies cited. Allegation, staff does not provide adequate supervision resulting in residents leaving facility is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Jul 9, 2024 · control 21-AS-20240528094749

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Jul 10, 2024

87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. Not met as evidence by** Based on a review of facility incident reports and resident records it was found that resident (R1) had eloped from the facility without supervision. R1 is diagnosed with dementia and based upon appraisal, requires special supervision for confusion and wander risk. This is an immediate health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 9, 2024

Plan of correction: Facility agrees to conduct staff training regarding elopements & updated R1's Physician's Report to better indicate their capabilities matching the level of care needed. Facility is to submit training date to CCLD by POC date 7/10/2024 and completed training by 7/23/2024. In addition, facility is to submit updated physician's report for R1 by POC date 7/23/2024.

Allegation investigated: Staff mismanaged residents' medication

On 7/9/2024, Licensing Program Analysts (LPA’s) Tobola & Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and were greeted by Acting Administrator, Mike Chatman. LPA’s toured the facility, reviewed resident medication supply and records, reviewed staff and resident records, interviewed staff and made observations during the course of the investigation. Complaint alleges, staff mismanaged resident's medication additionally indicating staff (S1) taking narcotics from the facility. Based on LPA spot review of medication supply and medication records, medications, narcotics and records for 3 out of 3 residents in memory care and 3 out of 3 residents in assisted living were found to be in order. During LPA observations during medication record keeping, administering and medication security protocols, LPA found that medtech staff (S2 & S3) appropriately handled medications and records. During a tour of the facility, LPA also found all medication storage carts to be secured and inaccessible to residents in care. Upon interviews with Director of Care and Resident Services (S2) & Resident Service Director (S3), medication destruction protocols were found to be properly implemented with no observed medications not properly disposed or destroyed. Lastly, upon review of S1's staff records LPA's did not find any corrective actions pertaining to allegation. Due to a lack of corroborating evidence, the allegation is unsubstantiated. Continued onto LIC9099-C Unsubstantiated Allegation, Staff mismanaged residents' medication is found to be UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Appeal Rights given.the state’s words, verbatim · CDSS document, Jul 9, 2024 · control 21-AS-20240611092503

Allegation investigated: Facility staff speak inappropriately to residents Facility staff restrain resident's in a rough manner Facility staff do not administer resident's medication as prescribed

On 7/9/2024, Licensing Program Analysts (LPA’s) Tobola & Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and were greeted by Acting Administrator, Mike Chatman. LPA’s toured the facility, reviewed resident medication supply and records, reviewed staff and resident records, interviewed staff and residents and made observations during the course of the investigation. Complaint alleges facility staff speak inappropriately to residents. Based upon interviews with multiple staff (S1-S8) there were inconsistent statements and a lack of corroborating information gathered to support the allegation. Complaint alleges facility staff restrain resident's in a rough manner. Based upon interviews with multiple staff (S1, S2, S3 & S4) there were inconsistent statements and a lack of corroborating information gathered to support the allegation. Continued onto LIC9099-C Unsubstantiated Complaint alleges, facility staff do not administer resident's medication as prescribed additionally indicating staff (S12) taking narcotics from the facility. Based on LPA spot review of medication supply and medication records, medications, narcotics and records for 3 out of 3 residents in memory care and 3 out of 3 residents in assisted living were found to be in order. During LPA observations during medication record keeping, administering and medication security protocols, LPA found that medtech staff (S2 & S11) appropriately handled medications and records. During a tour of the facility, LPA also found all medication storage carts to be secured and inaccessible to residents in care. Upon interviews with Director of Care and Resident Services (S9) & Resident Service Director (S10), medication destruction protocols were found to be properly implemented with no observed medications not properly disposed or destroyed. Lastly, upon review of S12's staff records LPA's did not find any corrective actions pertaining to allegation. Due to a lack of corroborating evidence, the allegation is unsubstantiated. Allegations, facility staff speak inappropriately to residents, facility staff restrain resident's in a rough manner and facility staff do not administer resident's medication as prescribed are found to be UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Appeal Rights given.the state’s words, verbatim · CDSS document, Jul 9, 2024 · control 21-AS-20240626090026

Allegation investigated: Staff hit resident Staff screams at residents

On 7/9/2024, Licensing Program Analysts (LPA’s) Tobola & Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and were greeted by Acting Administrator, Mike Chatman. LPA’s toured the facility, interviewed staff and outside parties and made observations during the course of the investigation. Complaint alleges facility staff hit resident. Based upon interviews with multiple staff (S1, S2, S3 & S4) there were inconsistent statements and a lack of corroborating information gathered to support the allegation. Complaint alleges staff screams at residents. Based upon interviews with multiple staff (S1-S8) there were inconsistent statements and a lack of corroborating information gathered to support the allegation. Continued onto LIC9099-C Unsubstantiated Allegations, staff hit resident and staff screams at residents are found to be UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Appeal Rights given.the state’s words, verbatim · CDSS document, Jul 9, 2024 · control 21-AS-20240617155026

Allegation investigated: Staff block facility exit doors Staff does not ensure resident's hygiene needs are being met

On 7/9/2024, Licensing Program Analysts (LPA’s) Tobola and Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and were greeted by Acting Administrator, Mike Chatman. LPA’s toured the facility, interviewed staff, reviewed resident and staff records and made observations during the course of the investigation. Complaint alleges staff block facility exit doors. Based upon interview with multiple memory care staff, (S1, S2, S3 & S4) there is confirmation of incidents in which staff observed furnishing items being used to block the exits of residents in the memory care unit during evening shifts. Complaint alleges staff does not ensure resident's hygiene needs are being met. Based upon, facility tour, LPA Mutialu observed resident (R1) on their wheelchair in their bedroom with soiled clothing (photos taken). In addition, based upon interviews with staff (S3 & S4) it was stated that residents have been left in soiled clothing/continence products without timely hygiene services met. Continued onto LIC9099-C Substantiated Allegations, staff block facility exit doors and staff does not ensure resident's hygiene needs are being met, are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 9, 2024 · control 21-AS-20240610105634

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(d)(6) · Plan of correction due date: Jul 10, 2024

87307(d)(6) Personal Accommodations and Services. All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirements is not met as evidenced by: Based upon interviews, multiple staff (S1, S2, S3 & S4) stated that they have observed memory care unit doors being blocked by furniture, which poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 9, 2024

Plan of correction: Facility agrees to ensure all exits are free from obstruction and submit a written statement on how facility will remain in compliance by POC date 7/10/2024. In addition, facility is to hold an in-service meeting with all caregiving staff to discuss compliance concerns of blocked passageways. Signed meeting attendance to be submitted to CCLD by POC date 7/23/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f) · Plan of correction due date: Jul 10, 2024

87464(f) - Basic services shall at a minimum include care and supervision as described in Health and Safety Code section 1569.2(c). These requirements were not met as evidenced by: Based upon LPA observation, resident (R1) was found left in soiled clothing (photos taken) In addition, interviews with staff (S3 & S4) stated observing residents being left in soiled clothing and not properly changed.the state’s words, verbatim · CDSS document, Jul 9, 2024

Plan of correction: Facility agrees to submit a written statement on how facility will remain in compliance by POC date 7/10/2024.

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

Type of visit: Case Management - Incident

On 6/27/2024, Licensing Program Analysts (LPA) Mutialu arrived unannounced for the purpose of a Case Management- Health and Safety Check regarding fire incident on 06/26/2024. LPA toured the facility and interviewed staff/clients Facility to provide updated Smoking Policy, process on preventing fires, how this process will be overseen, and Fire Marshall Report from 06/26/2024 to CCLD by 07/06/2024. No deficiencies cited.the state’s words, verbatim · CDSS document, Jun 27, 2024

Allegation investigated: Staff are not properly trained Staff are not attending to resident care needs in a timely manner

On 6/20/2024, Licensing Program Analysts (LPA’s) Tobola & Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and were greeted by Acting Administrator, Mike Chatman and Resident Service Director, Grace Montemayor. LPA’s toured the facility, reviewed resident medication supply and records, reviewed staff and resident records, interviewed staff and made observations during the course of the investigation. Complaint alleges, staff are not properly trained. Upon review of resident records and information provided by staff, it was found that resident (R1) requires a two-person assist along with the use of a hoyer lift. The review of training records revealed that 12 total caregiver staff received hoyer lift training as of 6/13/2024. However, training was not implemented prior to staff providing postural support and hoyer lift services to resident R1. Continued onto LIC9099-C Substantiated Complaint alleges, staff are not attending to resident care needs in a timely manner. Upon review of facility call bell system records, LPA’s found that on several occasions, call bells for residents (R2 & R3) had not been responded to between 1-3 hours. In addition, based upon interviews with staff (S1, S2 & S3), staff also do not find that they are able to adequately provide appropriate care to residents in a timely manner, also stating that it may take several hours to provide room checks, and not within the 2 hour room check protocols for residents. Allegations staff are not properly trained and staff are not attending to resident care needs in a timely manner are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Appeal Rights Given Allegation, centrally stored medications are accessible to residents in care is found to be UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Appeal Rights given.the state’s words, verbatim · CDSS document, Jun 20, 2024 · control 21-AS-20240516084802

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jun 21, 2024

87411(a) Facility personnel shall at all times be sufficient in numbers & competent to provide the services necessary to meet resident needs…This requirement has not been met as evidence by:** Based on records review of alarm response system and interivews with multiple staff Administrator did not ensure that staff on duty responded in a timely manner to call system to assist residents (R2 & R3) in care. Call bell response times were between 1-3 hours, which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jun 20, 2024

Plan of correction: Licensee failed to ensure staff responded appropriately to call bell system and meet resident care needs in a timely manner. Licensee shall conduct staff training on how call bells will be responded to and provide a 7 day alarm response log to Licensing along with training verification by POC due date 7/11/2024. In addition, Licensee to submit written statement on how future compliance will be met by POC date 6/21/2024.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(1) · Plan of correction due date: Jun 27, 2024

1569.625(b)(1) A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. This was not met as evidence by:** Based upon review of staff records it was found that 12 caregiving staff had received hoyer lift training on 6/13/2024, after resident (R1) had already been residing in the facility for several months requiring hoyer lift assistance. This serves as a potential health & safety riskthe state’s words, verbatim · CDSS document, Jun 20, 2024

Plan of correction: Facility failed to ensure staff had properly completed training requirements for dementia care and hoyer lift prior to staff providing direct care. Licensee agrees to ensure ALL staff that provide caregiving duties have received hoyer lift training. Training to be submitted to CCLD by POC date 6/27/2024. Lastly, faciltiy is to ensure all required training for caregiving staff both initial or annual are on fille.

Type of visit: Case Management - Other

On 6/20/2024, Licensing Program Analysts (LPA’s) Tobola & Mutialu arrived unannounced for the purpose of a Case Management to follow up on Administrator qualifications and were greeted by Acting Administrator, Mike Chatman (AA) and Resident Service Director, Grace Montemayor. The facility is currently in the process of assigning a designated Administrator for the care facility. AA provided proof of administrator re-certification from the Community Care Licensing Administrator Portal. In addition, AA stated that the Licensee is determining the final candidate and will provide LPA's with a time frame on when the Administrator will begin position. The Licensee and AA understand that facility must have active qualified Administrator and that the current status of the facility poses a potential health & safety risk as the previous Administrator had been removed from the facility as of May 16, 2024. No deficiencies cited.the state’s words, verbatim · CDSS document, Jun 20, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nakagawa arrived unnanounced to conduct a 1-Year Annual Inspection. LPA was welcomed by receptionist and asked to sign the visitor's book. LPA met with Yolanda Harrell, Administrator. There were 74 residents in care at the time of inspection. The facility provides both assisted living and memory care. LPA requested personnel and resident records for review. LPA found 5 of 5 resident records and 5 of 5 personnel records well-organized and complete. LPA then toured facility with Administrator. 10 resident rooms in memory care were inspected and found to be clean, orderly, and furnished as required by Title 22. The common areas of memory care were well-lit and staff were interacting with residents. There is a secure area for residents in Memory Care to access an outside walking path or sit outside on several benches. An inspection of the Assisted Living residence units found the apartments to be furnished appropriately, with bathrooms having the required grab bars and non-slip mats. Water temperature was within regulation. The ambient temperature of the building was between 72-74 F at the time of inspection. The kitchen was clean and well-stocked with an ample supply of perishable and non-perishable foods, as required per Title 22. LPA inspected fire extinguishers and found 10 out of 10 to be fully charged and last serviced on 11/10/2023. The Fire Department had inspected the facility on 10/1/2023. The facility's last fire drill was held on 2/14/2024. Elevators were last inspected on 6/14/2023. Continued on 809-C Continued from 809..... Stair chairs were installed at the top of each stairway as required and staff had been given a training on their use. The Hair Salon was in operation during LPA's visit and was found to be clean and sanitary. The medication rooms for Assisted Living and Memory Care use an E-Mar system and had the Centrally Stored Medication List available for review. Medications are live-poured and med carts are used for storage and delivery. Facility has a 30-day supply of medication for residents. Nurses are on site daily to help with medication management. The maintenance department had documentation showing their testing and temperature log for hot water. The facility has many outdoor areas for residents to use. LPA inspected and found them to be free of debris and ready for residents to enjoy. Administrator's certificate renewal had been processed and was currently pending. The following documents are requested for submission by 4/30/24: Current Lease Agreement or Control of Property Proof of Liability Insurance LIC 500 - Personnel Report Updated Disaster Plan There were no deficiencies found at the time of inspection. No citations issued. Exit interview conducted with Administrator.the state’s words, verbatim · CDSS document, Apr 17, 2024

Allegation investigated: Neglect/Lack of Supervision resulting in resident falls with injury(ies)

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced at Magnolia Court for the purpose of conducting a complaint investigation inspection and delivering complaint findings. LPA was greeted at the door by Administrator, Yolanda Harrell, and was granted access into the facility. During the investigation, LPA interviewed staff and outside parties, reviewed documents and made observations. Complaint alleges Neglect/Lack of Supervision resulting in resident falls with injury(ies). (Continued on 9099-C) Unsubstantiated Complaint alleges Neglect/Lack of Supervision resulting in resident falls with injury(ies). Review of pre-assessment and Physician's Report establishes that R1 was identified as a fall risk and required assistance as well as needing supervision due to confusion and restlessness prior to move-in. The Special Instructions created for R1's care state an escort to meals and activities will be provided, safety checks will be done at least 3 times per shift, and staff monitoring to maintain independence and safety. Other accommodations were also put in place, including keeping room free of clutter, clear pathway to bathroom and bed to lowest setting. Review of Staff Schedule indicates that staff was present at all times to provide R1's needs and services, monitoring and supervision. The facility provided constant communication with PCP, home health and family regarding the status of R1. Based on interviews, documentation and observation LPA could not substantiate the allegation. .A finding that the complaint allegation of Neglect/Lack of Supervision resulting in resident falls with injury(ies) is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Dec 5, 2023 · control 21-AS-20231204144402

Allegation investigated: Staff does not provide adequate supervision resulting in resident leaving facility.

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Magnolia Court for the purpose of conducting a subsequent complaint investigation inspection and delivering complaint findings. LPA was greeted at the door by Administrator, Yolanda Harrell, and was granted access into the facility. During the course of the investigation, LPA interviewed staff, residents and outside parties. LPA reviewed documents during the investigation. Complaint alleges that Staff does not provide adequate supervision resulting in resident leaving facility. Based on the interviews, LPA could not prove or disprove the allegation. LPA received inconsistent information regarding what actually transpired. LPA reviewed documents and found three Responsible Parties identified on the Emergency Contact form. During the incident in question, the resident left the facility with Responsible Party #3 who is allowed to take the resident on outings and outside of the facility. Facility was made aware that Responsible Party #3 was taking her to the front to get some fresh air, but departed from the facility with the resident shortly after. (Report continued on LIC 9099C) Unsubstantiated Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator. A finding that the complaint allegation of Staff does not provide adequate supervision resulting in resident leaving facility is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Nov 16, 2023 · control 21-AS-20231003122141

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Nov 27, 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. This requirement was not met as evidenced by: Based on an interview with the Administrator, staff did not adequately check on the resident and in turn provided inadequate information to the Responsible Party.the state’s words, verbatim · CDSS document, Nov 16, 2023

Plan of correction: Plan of Correction shall include the Licensee filling out an LIC 9098. In addition, Licensee shall submit a Plan for Future compliance and conduct staff training as it relates to communicating with Responsible Parties. POC due date on November 27, 2023.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Magnolia Court for the purpose of delivering complaint findings and conducting a Case Management-Other Inspection. LPA was greeted at the door by Administrator, Yolanda Harrell, and was granted access into the facility. During the course of the investigation, LPA learned via an interview with the Administrator that staff did not adequately check on the resident and make observations of the resident (See LIC 9102-Technical Violation). LPA educated the Administrator on the importance of regularly observing the resident in care. No deficiencies were cited during today's Case Management-Other inspection. Exit interview was conducted and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Nov 16, 2023