Marin Terrace

Allegation investigated: -Staff mismanaged resident medication.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Kathleen Devera, Administrator. An allegation regarding staff mismanaged resident medication. The Reporting Party stated that the facility is not documenting of medications administered, both routine and PRN including antipsychotics and opioid medications, bowel movements, objective findings during the care of R1, then for at least a week upon admission, staff were unable to secure appropriate medications and monitoring equipment, such as glucometer, that were prescribed to R1 after been discharged from the hospital. Based on interviews conducted with Administrator and facility medication technician (S6), they acknowledge that R1 has a diagnosis of diabetes, they confirmed that they received on 12/30/25 R1’s one touch glucometer, lancing device, test strips, but no lancets and R1 is unable to check their own glucose, but the facility has not been provided with a glucose check order to monitor R1’s daily glucose levels, which it was reported to home health nurse once. Continue on LIC9099C... Substantiated Continued from LIC9099 A... However, the facility provided resident’s records review, where there was an entry date 1/19/26 at 2:09pm indicates that R1 reported to staff (S1, S2 & S3) the alleged “abuse”, but the facility did not follow up on it. Also, on 12/12/25 there was another incident involving another resident (R2) where it was reported to facility management that staff (S4) was no longer welcome to care for R2 due to their incompetency when providing care and been always in a rush, getting defensive and other complaints that other staff raised about them, which resulted in management conducted an internal investigation and provided a written warning. LPA reviewed incident reports submitted to the Department and there were no incident reports regarding any of these reports. LPA will address in case management deficiencies discovered. A finding that the complaint allegation occurs of sexual assault 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. Another allegation of Personal Rights was received. Per Reporting Party, the facility staff withheld R1’s phone and refused to allow them to use the facility phone. On 1/26/26 and 2/27/26, LPA conducted 10-day visit and subsequent visit to investigate this allegation. Based on LPA’s interviews conducted with staff (S5 & S6) and residents (R1, R2 & R3) in care who are residents that carry their own cellphone with them stated that they maintain their devices handy and expressed that staff help them when they are unable to make a phone call, but there were no concerns regarding refusal to allow them to use the facility phone. Although staff interviewed revealed that residents have a history of dialing 911 constantly for non-emergency reasons. Based on records review, LPA requested service calls from Mill Valley Police Department for the month of December 2025, and January 2026 confirmed assistance provided by medical agencies needed and couple of wellness checks conducted on 12/24/25 and 12/26/25, but no areas of concern were determined after visits. Based on LPA’s observations during interviews conducted with R1, R2 & R3, they were able to locate their phones in their pockets or their drawers located next to their beds. Based on LPA’s observations, interviews and records review there was no supporting evidence to indicate that the violation could have happened at a prior date. A finding that the complaint allegation occurs of personal rights 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. Continued from LIC9099... Based on records review, R1’s physician report dated 12/23/25 and care plan address the need for a special diet due to glucose control needed, confirms that R1 is unable to perform own glucose testing. As of today, the facility did not follow up with R1’s physician or home health to obtain glucose check order and R1 has not been monitored their glucose levels since they were admitted back on 12/24/25. 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), is cited on the attached LIC 9099D. Appeal Rights Given.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 21-AS-20260126092155

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a) · Plan of correction due date: Mar 11, 2026

87628(a)Diabetes: licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens. This requirement is not met as evidenced by: Based on interviews & file review the licensee failed to ensure that resident (R1) was retained at the facility while not able to perform a glucose testing as per physician's report, but the facility did not followed up more than once to ensure R1’s glucose levels were monitored, which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Mar 10, 2026

Plan of correction: The Administrator agrees to ensure blood glucose testing is performed by an appropriately skilled medical professional or contact R1’s physician for current blood glucose order and submit plan to CCL to ensure a skilled medical professional is performing the test by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra conducted an unannounced required annual inspection of this facility and case management to cite deficiencies discovered during a complaint investigation #21-AS-20260126092155 met with facility Administrator Kathleen Devera. Annual fees current. LPA learned through records review and interviews with Administrator while investigating complaint #21-AS-20260126092155 that the facility has failed to follow up when resident (R1) reported to staff (S1, S2 & S3) on 1/19/26 at 2:09pm an alleged “abuse” has occurred. According to the Administrator, R1 has a history of been aggressive to staff, so it was presumed as another unfounded incident. On 12/12/25 there was another incident involving another resident (R2) where it was reported to facility management that staff (S4) was no longer welcome to care for R2 due to their incompetency when providing care and been always in a rush, getting defensive and other complaints that other staff raised about them, which resulted in management conducted an internal investigation and provided a written warning. LPA reviewed incident reports submitted to the Department and there were no incident reports regarding any of these reports. LPA/Administrator toured the building and grounds: The main building is two stories and currently there are eleven residents residing downstairs and four residents upstairs. Second building is single story and currently there are three residents. There were two staff and housekeeper staff present in the second building providing care and supervision to residents in care. Continue on LIC809C... Continued from LIC809... At approximately 10:00 am, LPA/Administrator observed that the elevator was last inspected on 11/20/23 and permit expired on 11/20/24. Per Administrator, they just came this week to inspect it, but there was no proof of service given. At approximately 10:15am, LPA/Administrator while touring the facility did not hear the auditory alarm when opening the door leading to second building located in the back of the facility. Per Administrator, the auditory alarm was not working and its being repaired. At approximate 10:30am LPA/Administrator observed hot water measurements of 78.8, 77.7, 135.5, 124 and 108.3 degrees which is not within regulation between 105 and 120 degrees F at faucets used by residents in care. Bathrooms have non-skid surfaces and grab bars at the toilet and shower areas. All medications were all locked and inaccessible to residents in care. Facility has cameras in both buildings in common areas. All common areas, hallways, and bathrooms observed had sufficient lighting. Residents rooms are furnished per regulation. The facility is on a delayed egress system and a locked perimeter courtyard for resident's use, which it was approved in their fire clearance. Evacuation chair was observed in the stairwell and documented in the facility emergency plan as indicated by the Department. The facility was a comfortable temperature. Passageways were free of obstructions. Facility has a sufficient supply of cleaners, hygiene items and paper products. Multiple first aid kits were observed. A call button is located in each bathroom and they are operational to alert staff. The amount of fresh and nonperishable foods is within regulation. A tour and inspection of the kitchens and dining areas were found to be clean and sanitary. Refrigerators and freezers were at required temperatures. Prepared and left over foods were covered and labeled. Menu includes a wide variety of foods from all of the food groups. A board in the kitchen has written instructions for residents with food allergies and restricted diets. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. The facility has a generator in case of power outages. Continue on LIC809C... Continued from LIC809C... Residents were observed participating in group activities in common areas. Fire extinguishers inspected were charged and dated 3/18/2025. Smoke detectors were tested in resident rooms. Facility has fire sprinklers throughout. Carbon Monoxide detectors were present and operational. The last disaster drill was conducted on 2/3/26. There were two garbage cans that do not have a lid/cover and ant observed in main bathroom located in the second building in the back of the facility (technical violation issued). At 11:00 AM, LPA conducted a file review of ten residents and five staff. One out of five staff (S4) do not have a health screening form on file including their TB test (technical violation issued). Three out of five staff (S1, S3 & S5) do not have current 1st aid or CPR certificates updated. All staff have completed all required training hours. Residents receiving hospice services had a care plan that appears to be accurate to services being provided. All residents' care plans seems to have a person-centered approach and they are updated. Medical assessments are current and included a description of any known behavioral expression. One out of ten residents (R2) does not have half bed rails order on file (technical violation issued). Kathleen Devera, administrator certificate 6069816740 expires on 10/18/2026. Medication is centrally stored and locked in medication cart located at the medication room. A sample of medication and medication records reviewed. Updated copies of the following documents need to be submitted to CCL by not later than 3/23/26: LIC500- Personnel Report. LIC308- Designation of Responsibility. LIC610E- Disaster Plan (if there are any changes). Evidence of Liability Insurance. Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Given. Exit interview was conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Mar 10, 2026

The state marks this report as 10 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

02/27/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 25 residents in care. Facility approved/cleared for 49 non-ambulatory, of which 10 may be bedridden, and hospice waiver for 20. At approximately 10:20am, LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated. Facility has extra food and PPEs located in the garage/storage room. The main building is two stories. The second building is single story and currently there are three residents, LPA observed a staff member with a resident in the living room area. LPA observed an out of order sign for one of the two washer machines. Per conversation with administrator they have put in a work order for maintenance to come out and replace/fix it. LPA observed all exits doors to have working alarms. LPA observed 1 evacuation chair located around the corner from stairwell #1 but no evacuation chair at stairwell #2 that leads outside the building (Technical Violation Issued). LPA suggested for facility to have a sign up on the wall indicating the location of the evacuation chair for stairwell #1. Department of Social Services will reach out to Fire Marshall's to discuss the placement of the evacuation chairs. LPA observed All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured at 110.6, 110.3, and 117.7 which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 04/2024. Facility has fire sprinklers throughout. Toxins are stored in a locked laundry room. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. LPA conducted review of 5 staff records/training. Upon a review of staff records, LPA found 4 out of 5 staff (S1, S3, S4, S5) to be missing required annual and/or initial training (Deficiency Issued). LPA observed S3 to be missing current 1st Aid & CPR certification on file. LPA conducted a review of 5 resident records. LPA observed 2 out of 5 residents (R1 and R2) to not have updated physicians report (Technical Violation Issued). continued on LIC809-C Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/27/2025: LIC500- Personnel Report LIC308- Designation of Responsibility Infection Control Plan (review, update if needed) Emergency Disaster Plan (review, update if needed) Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 27, 2025

Allegation investigated: Staff do not meet resident's incontinence needs Staff take away a resident's night call button

Licensing Program analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation statements were taken, documents obtained and reviewed as well as site visits made to the facility. The following determinations are made: Complainant alleges that facility staff took resident's ( R1's) call button from R1 and that photos exist that show R1's incontinent needs were not met; R1 denies staff took R1's call button; Complainant has not produced photos of R1's neglected incontinent needs; R1's Physician's Assessment dated 6/2/2024 does not indicate R1 is incontinent; R1 states that staff did not meet R1's incontinent needs; Facility Administration state R1 requested incontinent briefs in order to avoid getting out of bed at night. Although the allegation may be true, based upon the statements and documents, there is not a preponderance of evidence to prove, or disprove, the allegations. Therefore, the allegations are UNSUBSTANTIATED. Report Left. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 15, 2024 · control 21-AS-20240701143513

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Oct 15, 2024

87465(e) Incidental Medical and Dental Care. For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication… Based upon statements, this requirement not met as evidenced by: An OTC sleep aid was observed in R1’s room which was not prescribed by R1’s physician. This posed an immediate risk to R1’s health.the state’s words, verbatim · CDSS document, Oct 15, 2024

Plan of correction: Cleared at time of visit. Facility has provided refresher training to staff on the requirements of 87465.

Allegation investigated: Staff did not meet a resident's incontinence needs Staff mishandled a resident's medication

Licensing Program analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation statements were taken, documents obtained and reviewed as well as site visits made to the facility. The following determinations are made: It is alleged that staff did not meet resident's (R1's) incontinent needs and that staff mishandled R1's medication; This investigation found no evidence of neglected incontinent needs for R1; Medication Administration Record for R1 suggests that one dose of a topical creme prescribed for R1 was not administered; Administration states that the dose was administered but not recorded due to a miscommunication between the staff administering the medications to residents. Although the allegations may be true, based on the statements and documents reviewed, there is not a preponderance of evidence to prove, or disprove, the allegations. Therefore, the allegations are UNSUBSTANTIATED. Report left. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 15, 2024 · control 21-AS-20240911120712

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Oct 22, 2024

87465(a)(1) Incidental Medical and Dental Care. The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. ***Based on statements and documents, this requirement not met as evidenced by: R1 sustained rash for approximately 4 weeks prior to receiving medical treatment arranged by facility. This posed an immediate risk to the health of R1.the state’s words, verbatim · CDSS document, Oct 15, 2024

Plan of correction: Administration to review the requirements of 87465 and will submit a written declaration confirming compliance to CCL by POC date in order to clear the deficiency.

Allegation investigated: Staff did not seek timely medical care for resident

Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:30AM to deliver findings regarding the above allegation. LPA and Administrator discussed the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews, made observations, and reviewed documents. Complaint alleges that staff did not seek timely medical care for resident. LPA received a report from facility on 4/15/2024 indicating that Resident 1 (R1) was found not breathing in their room at approximately 4:30AM while NOC shift caregivers were doing their routine rounds. Report states that EMT pronounced R1 deceased at 6:12AM. Continued on LIC9099C Substantiated Continued from LIC9099 Interviews conducted revealed that caregivers report to medication technicians when there is an emergency, and the med techs determine whether or not they should call 911. Per interviews conducted, caregivers found the resident to be deceased and immediately called the Administrator of the facility. Caregivers had attempted to get in contact with R1s responsible party as they wanted the responsible party’s permission before calling 911. Administrator called Staff 1 (S1) to immediately go to the facility and assess the situation. When S1 arrived to the facility, they immediately called 911. Investigation confirmed that there was a 90 minute delay in calling paramedics due to the facilities procedures for determining when to call emergency services. Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore the above allegation was found to be SUBSTANTIATED. Deficiencies are 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 conducted. Copy of report, LIC-9099D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 19, 2024 · control 21-AS-20240417101040

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Jul 20, 2024

(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis... This requirement was not met as evidenced by: based on document review and interviews conducted, the licensee did not comply with the section cited above by not contacting emergency services in a timely manner.the state’s words, verbatim · CDSS document, Jul 19, 2024

Plan of correction: Administrator agrees to submit proof of in-service training for all direct care staff regarding how to determine when to call 911. Proof of training must include: staff names with signatures, dates, topics covered, who conducted the training, etc. Proof to be submitted by POC due date 08/02/24.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Cuadra and Rummonds made an unannounced required annual inspection of this facility and met with facility acting Administrator Erlinda Ferris. Annual fees current. LPAs/Administrator toured the building and grounds which was found to be clean and in good repair. The main building is two stories and currently there are seven residents residing upstairs. Second building is single story and currently there are two residents. At approximate 10am LPAs/Administrator did not observe assigned staff in the second building providing care and supervision to resident in care who has a non-ambulatory status as indicated in their facility plan of operation. Assigned staff was walking into the second building as we were touring the facility. LPAs reminded the Administrator the requirement to have an assigned staff at all times in the second building to assist residents in care. Administrator could not provide a reasonable explanation regarding the absence of assigned staff in the second building. Medication is centrally stored and locked in medication cart and closet. A sample of medication and medication records reviewed. Facility has cameras is both buildings in common areas. However, at approximate 10:05am LPAs/Administrator observed cameras located in private room #2 and 26. Per Administrator, resident's responsible parties brought the cameras without permission. LPAs/Administrator also smelled several bathrooms has a strong urine odor. LPAs/Administrator did not observe any CCL's reports placed in a conspicuous place. Also, the facility does not have required CCL complaint poster. A technical violation will be issued. At approximate 10:30am LPAs/Administrator observed hot water measurements of 129.3, 132, 145.2, 136 and 146.8 degrees which is not within regulation between 105 and 120 degrees F at faucets used by residents in care. Fire extinguishers inspected were charged and dated 4/5/2024. Smoke detectors were tested in resident rooms. Facility has fire sprinklers throughout. Carbon Monoxide detectors were present. The last disaster drill was conducted on September 27, 2023. Continued on LIC809C... Continued from LIC809... Residents have emergency pull cords in restrooms, call buttons at bed side and facility uses Wander Guard alert system. All auditory devices sound in the kitchen and light indicated alert in Administrator office. The amount of fresh and nonperishable foods is within regulation. LPA toured the kitchen and dinning areas. At 10:45 AM LPAs/Administrator observed expired canned goods, unpacked dry good not with expiration dates noted in the food pantry storage and unlocked laundry room with toxins and cleaning supplies accessible to residents in care. Also, LPAs/Administrator did not observe any auditory alarm on the second story door located in the main building, which leads to steep stairs. Hoyer lift used for residents in care was tested and it was found operational during the visit. However, staff observed might receive additional training to operate this type of equipment. A discussion with Administrator was handled to explain the importance of staff having better knowledge in how to operate the hoyer lift equipment properly. LPAs initiated file review at 11am. Five residents and five staff files were reviewed. Four out of five staff (S1, S2, S3 and S4) did not have a current CPR/1st aid on file. Two out of five staff (S1 and S2) do not have a health screening including TB test on file. Five out of five staff (S!, S2, S3, S4 & S5)do not have required annual training hours completed on file. Five out five residents (R1, R2, R3, R4 & R5) who has a diagnosis of dementia need an updated medical assessment and care plan. Several residents have half bed rails, but they do not have a doctor's order on file for use of half bed rails. Per Administrator, they had been working with resident's physician to obtain one for each of them. Administrator certificate for administrator Erlinda Ferris 6054488740 expires on 12/8/25. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this inspection: LIC500- Personnel Report. LIC308- Designation of Responsibility. LIC610E- Disaster Plan. Evidence of Liability Insurance. Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Given. Exit interview was conducted with Administrative assistant who was informed that the Department will be reviewing if further action is needed to address the overall compliance of the facility and a copy of this report was given.the state’s words, verbatim · CDSS document, Apr 23, 2024

The state marks this report as 12 pages; the online copy we transcribed has 10. You can request the full file from the county licensing office.

Type of visit: Office

An informal meeting was conducted today via Microsoft Teams. Present in the virtual meeting were Licensing Program Manager Bethany Moellers, Licensing Program Manager Victoria Bertozzi, Licensing Program Analyst Helena Rummonds, Licensing Program Analyst Marisol Cuadra, Licensee Dinesh Sawhney, acting Administrator, Erlinda Ferris, other attendees Rico Foz, Meryl Foz and Payam Saljoughian. The purpose of the informal office meeting was to discuss areas of non-compliance and observed and ongoing Community Care Licensing concerns of the operation of Marin Terrace #216803891. The Attendees were 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. The legal administrative action process was explained to attendees which is based on substantiated complaint findings found on complaint investigation. Items addressed in today's meeting include but are not limited to patterns and trends in the areas below: Personal Rights including resident ADLs not provided as assessed in their care plans. Timely seek for medical care by assisting residents in a timely manner. Reporting Requirements of incidents occurred at the facility were not notified to CCL Personnel Requirements including lack of staffing to meet resident’s care needs. Basic Services include providing residents with a menu that meets the recommended dietary allowances of the Food and Nutrition Board of the National Research Council. Acting administrator and involvement in the facility operation. Continued on LIC809C... Continued from LIC809... Documents requested during informal meeting to be submitted to CCL by 04/19/2024: · Updated Personnel Report (LIC 500) including staff assigned to provide assistance to residents located in the back building. · Administration Organization (LIC309) · Licensee to ensure the facility has a current Administrator or submits required documentation to change in Administrator: LIC215, LIC500, LIC501, current Administrator certificate and detailed employment/education history. · Licensee to develop policy identifying staff member responsible for ensuring all deficiencies are addressed, special incident report is submitted to designated agencies. Failure to submit the above documentation may result in the Department seeking further action. The licensee was informed that civil penalties are under review by the Department per Health and Safety Code 1569.49 (f) due to substantiated complaint # 21-AS-20231128151806. No deficiencies cited during today’s informal virtual conference visit. Copy of this report will be emailed to obtain signatures.the state’s words, verbatim · CDSS document, Apr 11, 2024

Allegation investigated: -staff did not provide adequate supervision to resident in care. -Staff failed to seek timely medical care for residents. -Staff did not assist a resident with showering and toileting. -Staff violated residents’ rights. -Staff did not ensure resident was provided proper nutrition.

Licensing Program Analyst Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Nickolas Thompson, lead med-technician. Administrator Erlinda Ferris was off for the day, but she was available by phone and gave authorization for staff to sign the report. There is an allegation staff did not provide adequate supervision to resident in care. Per the reporting party, R1 was left with part of their body outside of the bed for an unknown amount of time. On 11/21/23, it was decided to hire a full-time one-on-one caregiver due to concerns about care and supervision not being provided to R1. Based on records review, on 10/17/23 R1’s physician ordered R1 to receive hospice services due to concerns about rapid decline of R1’s health, fall risk, care and supervision concerns. Also, the physician ordered the facility staff to assist with bathing, toileting, continence, dressing, transfers, assisted daily living activities (ADLs) as well as inspect R1’s skin by repositioning them every two-three hour to prevent them from pressure injuries ensuring that call light is located within reach to R1. Continue on LIC9099C... Substantiated Continued from LIC9099... On 11/21/24 the outside party reported that there were no facility staff coming to perform prescribed reposition checks on R1 every two-three hour as prescribed by their physician. LPA obtained a picture of R1 found sleeping on the floor. The administrator confirmed that facility staff were not assisting R1 that night and ensured that it did not happen again. Per Administrator, the facility implemented a communication log for staff to document their checks. LPA was provided with logs between 10/17/23 to 11/22/23 where on different dates (10/24/23, 10/26/23,10/28/23, 10/31/23 and 11/2/23), staff reported that R1 was knocking on the back door of main building trying to come inside the facility. Based on interviews conducted with facility staff, it was revealed that night shift staff will lock the back door of the main building of the facility to block R1 from coming into the facility, and not checking on them to ensure that any possible care needs were met. 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), is cited on the attached LIC 9099D. Appeal Rights Given. Regarding the allegation of staff failed to seek timely medical care for residents. Per Reporting party, on 11/2/23 Administrator notified R1’s responsible parties that R1 was out of control, reporting property damage to the flower garden and sink, but not reporting any injuries. However, based on records review of skin integrity monitoring form on 11/4/23 R1 was found around 3pm by staff with a big bruise on their right leg. On 11/7/23 at 10:40am hospice records confirmed that facility did not report any falls to them, but R1 was observed by hospice nurse with significant bruising. On 11/13/23 hospice records confirmed that the facility administrator notified them about R1’s aggressive behavior and destruction of property. Per hospice records, on 11/17/23 at 2:18pm, they were notified by an outside party that R1 was found lying on the floor and staff told them that this “has been happening a lot”. However, the facility did not notify responsible parties about it. On 11/20/23 the hospice agency scheduled R1 for x-rays to be done where results were negative for any fractures. On 11/21/23, R1 was found unconscious with a dropped jaw and staff disclosed to an outside agency that R1 sustained the injuries and decline in health because a sink fell on them weeks earlier. The reporting party expressed that it seemed like an unknown staff found R1 injured and physically moved R1 to their bed without assessing or attempting to seek medical treatment for R1. Staff tried aggressively shaking and yelling at R1 to wake them up and feed them without notifying hospice about the incident. According to hospice documents obtained indicates that on 11/22/23 hospice had a discussion with the administrator to ensure communications of R1’s condition to ensure timely hospice and medical care was provided. Therefore, LPA reviewed incident report logs for this facility, and it was determined that incident reports were not submitted to CCL. Continues on LIC9099C... Continued from LIC9099C... The administrator could not provide proof that incidents were reported to CCL nor responsible parties. LPA will address reporting requirements on a case management inspection. 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), is cited on the attached LIC 9099D. Appeal Rights Given. Another allegation of staff did not assist a resident with showering and toileting. On 11/18/23, R1 started receiving services from a private caregiver who was hired part-time to provide companion to R1 due to safety concerns. Per the reporting party, staff did not want to change or bathe R1 and wanted the private sitters or the responsible parties to do it supposedly due to their aggressive behavior. Based on records review, this allegation had been previously investigated and determined Substantiated under complaint# 21-AS-20230918101730. However, on 10/14/23 R1 came back to the facility and staff still did not assist R1 with shower and toileting. Based on interviews conducted with the Administrator, LPA confirmed that R1 returned from hospital with no aggressive behaviors due to medication adjustments made by their physician. On 11/18/23, private caregiver reported that facility staff did not come to check on R1 until 4am. Based on hospice records confirmed concerns with showering and toileting needs been met for R1. 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), is cited on the attached LIC 9099D. Appeal Rights Given. Last allegation about staff violated residents’ rights. Per reporting party, on 11/17/23 they arrived unannounced to the facility to visit R1, but two staff started running to the back building where R1 was residing, so outside party did run as well behind them and found R1 unattended on the floor wearing only pull-up diaper. LPA obtained a picture showing R1 laying on the floor with a staff standing next to them. Based on interviews conducted with outside party, who confirm to LPA the incident, they were told by staff that they were checking on R1 every two hours, and they ensured that they were just there checking on them five minutes ago. However, outside party touched the bedsheets that were cold, then they requested staff to help them to have R1 transferred to bed, but staff replied that they will have to wait until med-technician or someone else who’s job it was to assist R1 with transferring to their bed. 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), is cited on the attached LIC 9099D. Appeal Rights Given. Continues on LIC9099C... Continues from LIC9099A... A finding that the complaint allegation occurs of staff did not allow residents to have visitors 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. Regarding allegation of resident sustained multiple unexplained injuries while in care. Per reporting party, resident (R1) sustained unexplained injuries causing soreness and discoloration to their extremities. Reporting Party reports the resident was found sleeping on the floor. Based on records review, the reporting party alleges R1 was receiving hospice services on an average of two-three visits per week for symptom management. On 11/2/23 Administrator notified R1’s responsible parties that R1 was out of control, reporting property damage to the flower garden and sink, but not reporting any injuries. Based on LPA’s records review of skin integrity monitoring form on 11/4/23 R1 was found around 3pm by staff with a big bruise on their right leg. However, hospice records revealed that they conducted a visit to R1 on 11/6/23 at 1:24pm and the facility did not report anything to them. On 11/7/23 at 10:40am hospice records revealed that facility did not report any falls, but R1 was observed by hospice nurse with significant bruising on right hip with worsening bruising on right upper/inner/posterior thigh, bruise to left temple. On 11/7/23 at 11:42am hospice records indicated that there was a meeting held to discuss suspected fall last week, where it was determined that unexplained injuries and bruises were a result of a fall, the discussion it was unclear if recent decline was due to suspected fall, medication changes or generalized decline, but it raised concerns about limited supervision provided by facility staff, and suggesting hiring temporary staffing for R1 to ensure their safety. Also, there was another incident dated 11/10/2023 revealing that R1 was found by staff on the floor around 12:50pm, later that day R1 pulled the sink out of the wall, broke shower handle and pulled on blinds breaking them as well. On 11/20/23 the hospice agency scheduled R1 for x-rays to be done where results were negative for any fractures. LPA is substantiating not adequate supervision due to findings of main building lock door at night. A finding that the complaint allegation occurs of resident sustained multiple unexplained injuries while in care 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. Continued from LIC9099C... Staff did not ensure a resident was provided proper nutrition. Per reporting party, staff did not provide meals to R1 because they said that R1 do not eat, R1 passed away on 11/23/23 and concerns were raised if malnutrition contributed to the R1’s decline. Based on records review, facility communication log starting on 11/6/23 indicates a decline in percentage of meal intake of R1 from 100% to 50%, 11/7/23 – 25% pm shift, 11/13/23 – 0% due to “R1 was sleeping all day”, but another log dated 11/13/23 at 5:30pm R1 ate 25%, 11/14/23 - 20% at 5pm, 11/15/23 – 30% at 5:30pm, 11/16/23 – 30% pm shift, 11/17/23 – 20% dinner, 11/20/23 – 45% pm shift, 11/21/23 – 30% pm shift and 11/22/23 – 0% pm shift. On 11/21/23 the private caregiver reported via text message that facility staff did not bring any water or food the entire night, the facility staff will not provide food or water to R1 unless it was requested by them. Also, outside agency records indicated that on 11/21/23 they reached out to the Administrator to remind them of staff duties with R1. Also, outside agency records revealed a weight loss of 30 lbs. within the last year as follow: 10/25/22 – 180lbs to 9/15/23 – 151lbs. Based on interviews conducted with an outside party, on 11/20/23 they arrived at the facility unannounced at approximate 5:15pm, R1 was found with their legs in the bed and their torso hunched over the chair located next to their bed enabling R1 to move, it was unclear for how long time had been stuck in this position, when staff was asked by what time was the last time that they have checked on R1, they were told that two hours ago (3:15pm), then it was noticed that the entire community was eating, so they asked when dinner was going to be brought to R1, and staff replied to them that R1 was already fed with their dinner at 3:15pm. Per Administrator, it was confirmed that it was brought to their attention about caregivers were not assisting R1 with ADLs including meals due to caregivers were afraid of R1, and the administrator talked to staff to remind them about their duties with R1. Therefore, R1 wasn’t offered snacks and meals contributing to their weight loss. Based on facility communication daily log failed to report it to hospice agency. 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), is cited on the attached LIC 9099D. Appeal Rights Given. The Department will be scheduling a meeting to discuss areas of concern. Exit interview was conducted with Administrator over the phone and copy of this report was given.the state’s words, verbatim · CDSS document, Mar 4, 2024 · control 21-AS-20231128151806

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1569.269(a)(6) · Plan of correction due date: Mar 5, 2024

§1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (6) To care, supervision, & services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement has not been met as evidence by: Based on LPA’s records review and interviews. The facility staff did not ensure that R1 was provided with adequate supervision by locking the back door of the main building blocking R1 from coming inside as well as staff not going to check on R1 every two-three hour as ordered by their physician, which is an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Mar 4, 2024

Plan of correction: The Licensee/Administrator agrees to submit a plan to ensure facility is following up on resident’s needs and observation of the resident to CCL by POC due date to clear the citation. *Immedicate civil penalty issued in the amount of $250 for repeated violation within 12 months (11/2023). Administrator was informed that the Department will be scheduling an informal virtual office meeting to address areas of concerns & overall compliance of the facility.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Mar 5, 2024

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement has not been met as evidence by: Based on LPA’s records review and interviews. The facility staff failed to call 911 or other medical personnel as the hospice agency after R1 had a fall and changes of conditions, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 4, 2024

Plan of correction: The Licensee/Administrator agrees to submit a plan regarding timely medical care after resident’s fall and will train staff as to the regulation. Administrator agrees to send proof of training & written fall plan in how to ensure what staff are to do after a fall to CCL by POC due date to clear the citation. Administrator was informed that the Department will be scheduling an informal virtual office meeting to address areas of concerns & overall compliance of the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 25, 2024

87411 Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, & competent to provide the services necessary to meet resident needs...ensure provision of personal assistance & care...This requirement has not been met as evidence by: Based on interviews conducted and records review. Facility staff did not assist R1 with shower & toileting as ordered by their physician supposedly due to their aggressive behavior after R1 came back from hospital, which poses an immediate risk to the health and safety of the residents in care.the state’s words, verbatim · CDSS document, Mar 4, 2024

Plan of correction: Administrator agrees to submit a written plan in how staff will assist residents with showering & toileting at all times by POC due date. Administrator was informed that the Department will be scheduling an informal virtual office meeting to address areas of concerns & overall compliance of the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(3) · Plan of correction due date: Mar 25, 2024

87464 Basic Services (f) Basic services shall at a minimum include: (3) Three nutritionally well-balanced meals and snacks made available daily, including low salt or other modified diets prescribed by a doctor as a medical necessity…This requirement has not been met as evidenced by Based on LPA’s observation, records review and interviews with the administrator revealing that facility was not providing meals that meet Recommended Dietary Allowances. This is a potential risk to residents in care.the state’s words, verbatim · CDSS document, Mar 4, 2024

Plan of correction: Facility agrees to submit a planned menu that meets the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council by POC due date to clear the deficiency. Administrator was informed that the Department will be scheduling an informal virtual office meeting to address areas of concerns & overall compliance of the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Mar 25, 2024

87468.1 Personal Rights of...(a) Residents in all RCFE shall have all of the following personal rights: (2) To be accorded safe, healthful & comfortable accommodations ...This requirement has not been met as evidence by: Based on LPAs observation and record review the facility failed to ensure resident's R1 personal rights where met when R1 was found unattended on the floor wearing only pull-up diaper, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 4, 2024

Plan of correction: Administrator agrees to submit a written plan to ensure facility is following up on residents’ needs by POC due date. Administrator was informed that the Department will be scheduling an informal virtual office meeting to address areas of concerns & overall compliance of the facility.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility to conduct a case management visit to cite deficiencies discovered during a complaint investigation and met with Nickolas Thompson, lead med-technician. Administrator Erlinda Ferris was off for the day, but she was available by phone and gave authorization for staff to sign the report. LPA learned through records review and interviews with Administrator had failed to provide incident reports to CCL and resident's (R1) responsible parties including hospice about R1's incidents of falls. Per hospice records, on 11/17/23 at 2:18pm, they were notified by an outside party that R1 was found lying on the floor and staff told them that this “has been happening a lot”. However, the facility did not notify responsible parties about it. According to hospice documents obtained indicates that on 11/22/23 hospice had a discussion with the administrator to ensure communications of R1’s condition to ensure timely hospice and medical care was provided. The Department will be scheduling a meeting to discuss areas of concerns and non-compliance for complaint # 21-AS-20231128151806. 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 conducted with Administrator over the phone and a copy of this report was given.the state’s words, verbatim · CDSS document, Mar 4, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Mar 25, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require…(1) A written report shall be submitted to the licensing agency & person responsible for the resident within 7 days of the occurrence of any of the events…(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement has not been met as evidence by: Based on LPA’s records review and interviews conducted Administrator did not ensure that CCL was notified of incidents involving R1 after falls. Per hospice records revealed that R1 had incidents of falls and changes of conditions that were not reported to them nor CCL, which poses a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 4, 2024

Plan of correction: Administrator to ensure all incidents that threaten the safety of residents are reported to CCL per regulation. Administrator to review regulation, contact an outside vendor to conduct training for all staff on reporting requirements. Signed statement that the regulation was reviewed & sign in sheet for all staff trained to be submitted by POC due date. Administrator was informed that the Department will be scheduling an informal virtual office meeting to address areas of concerns & overall compliance of the facility.

Allegation investigated: -Staff did not provide proper assistance to resident in care.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with acting Administrator Erlinda Ferris. There is an allegation that staff did not provide proper assistance to residents in care. Per reporting party, resident (R1) often becomes physically aggressive with staff resulting in staff not been able to assist with showering in the past two months. Based on LPA’s interview conducted with acting Administrator, R1 has a behavior and will be assisted with bathing “only once a month, R1 does not get a sponge bath, does not get a change of clothes for days or weeks and will attempt to leave the facility, due to their agitated behavior will run after caregivers that attempts to provide care, which is interpreted as refusal of services by the facility staff.” Per acting Administrator, a times R1 may be given a PRN due to aggressive behaviors. However, R1 is uncooperative in taking their medications, so it has been a huge challenge to provide care for R1. Continued on LIC9099C... Substantiated Continued from LIC9099... On 9/19/23 LPA conducted confidential interviews with staff that confirmed staff have not been assisting R1 with regular daily living activities due to R1’s aggressive behavior that they make them feel afraid of resident, so they leave them alone. Based on records review, facility provided LPA with a copy of R1’s daily progress notes for the months of August and September 2023, it was revealed that on 8/1/23 resident was assisted with dinner only, 8/3/23 R1 refused three times to take a shower when offered by staff, (8/15/23, 8/25/23 and 9/14/23) R1 was aggressive with staff, then on 9/15/23 R1 had to be transported to the Hospital due to their aggressiveness and difficulty of staff to care for them. LPA was provided with an incident report confirming the situation where responsible parties were notified. LPA obtained outside agencies reports, which confirmed through interviews conducted with staff that R1 has not bathed in two to three weeks due to their behavior. On 10/3/23, co-complainant added to the same allegation reporting that facility staff identified the reason for not providing care to R1, to be their behaviors. Additionally reported a decrease in food intake, which may be due to R1’s refusal to eat or lack of food being provided to R1 by facility. However, based on records review of R1’s hospital records, there was a concern about intake refusal to eat, but weight data taken on 9/15/23 revealed that R1 has gained weight increasing to 151 pounds from last encounter on 5/29/23 reading of 143 pounds. LPA reviewed R1’s physician report and care plan that indicates facility will assist R1 with showers at least twice per week. 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), is cited on the attached LIC 9099D. Appeal Rights Given.the state’s words, verbatim · CDSS document, Nov 20, 2023 · control 21-AS-20230918101730

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1569.269(a)(6) · Plan of correction due date: Nov 21, 2023

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement has not been met as evidence by: Based on LPA’s records review and interviews conducted with staff, the Administrator did not ensure that resident (R1) was assisted with proper care while residing in the facility, which poses an immediate risk to the health & safety of resident in care.the state’s words, verbatim · CDSS document, Nov 20, 2023

Plan of correction: Administrator agrees to submit a plan to ensure facility is following up on resident’s care needs to CCL by POC due date.