Memory Care of Contra Costa

Type of visit: Office

On September 3, 2026, beginning at 10:00 a.m., an Informal Meeting was held via video conference with the Licensee and management representatives. The Informal Conference process was explained to the Licensee and management representatives. Attendees: Community Care Licensing Division (CCLD) Grace Luk – Licensing Program Manager Jeremy Fong – Licensing Program Manager Lizette Chan – Licensing Program Manager Lori Alexander – Licensing Program Analyst Licensee and Management Representatives Tracey Ingleman – Executive Director, Carlton Senior Living LLC Lindsey Flores - Sr. Vice President Marybel Parker - Regional Memory Care Director Sanjuana Casillas – Administrator Designee, Golden Crest Senior Living Ann Zavela, RN – Regional Market Leader for Operations Roanne Delos Reyes, LVN – Regional Clinical Market Leader for Wellness Vanessa Vasquez Tovar, LVN – Clinical Director, Santa Maria Melissa Hawley, LVN – Clinical Director, Memory Care of Contra Costa Jonathan Centeno – Wellness Coordinator, Memory Care of Contra Costa LIC809-C (Page 2) Type A Deficiency: cited on 07/15/26 for a case management visit to address an resident elopement that occurred on 07/08/26. 87468.2 (a)(4) Additional Personal Rights of Residents in Privately Operated Facilities During the meeting, facility management staff provided detailed information explaining the circumstances pertaining to the elopement. The facility management staff also provided information showing that a good faith effort has been made to address persons who cannot leave unassisted from exiting unnoticed. Facility management stated and provided the following plan of action: Increased front desk staff to 16 hours and with a plan to increase 24/7 staffing Conducted Elopement In-Service training with all staff on all shifts Installed Ring Alarm Applying for a permit to add egress doors Implemented twice daily door checks Established 24/7 staffing at rear nursing station Utilizing a system that reminds staff to perform required tasks Ordered wearable GPS bracelet devices Exit interview conducted and copy of this report provided via email. Memory Care of Contra Costa - #075601363 - Informal Meeting - 09.03.26 (part 1) - signed.pdfthe state’s words, verbatim · CDSS document, Sep 3, 2026

Type of visit: Case Management - Health Checks

On this day, 8/26/26, at 12:20 pm, Licensing Program Analyst (LPA) Delmundo conducted a case management inspection to ensure the health and safety of residents as a result of the Department receiving a Priority 1 complaint (Complaint Control # 15-AS-20260820124051). LPA met with Back-up Executive Director (BED) Jonathan Wheeler and informed the reason for visit. Executive Director (ED) Sanjuana Enriquez-Casillas arrived at around 1:45 pm. LPA toured the facility with BED. LPA inspected the activity area, courtyard, dining room, kitchen, restrooms, shower room, 2nd dining room with kitchenette. LPA randomly selected 6 residents rooms for inspection. During inspection, LPA observed 4 residents in the activity area, 1 resident in the courtyard and 9 residents in the 2nd dining room. LPA observed the storages, beauty salon and electrical and laundry rooms locked. LPA observed the following: at 12:31 pm, 6 rakes and shovel in 1 gardening bag and 5 rakes and shovel in another gardening bag hanging on the side of each of the 2 mobile planters in the courtyard. Deficiency is cited from Title 22 California Code of Regulation and listed on 809D. A $250.00 civil penalty is assessed for repeat violation of section # 87309(a) within 12 month period. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty. Deficiency, plan and proof of correction and civil penalty were discussed with ED. Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, LIC9098 Proof of Correction form, and copy of this report provided.the state’s words, verbatim · CDSS document, Aug 26, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Aug 27, 2026

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage.... ....and are not left unattended if outside the locked storage. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with section above in gardening tools unlocked in the courtyard which pose an immediate safety risks to persons in care.the state’s words, verbatim · CDSS document, Aug 26, 2026

Plan of correction: Back-up Executive Director took the items and have them locked. In addition, Executive Director to in-service the staff and submit copy of training topic with attendees signatures by 8/27/26.

Type of visit: Case Management - Incident

On 07/15/2026 at 4:30 PM, Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident reported to Community Care Licensing Division (CCLD) on 07/10/2026. LPA met with Executive Director, Diane Perez, and Market Leader, Ann Zavela, and explained the purpose of the visit. Community Care Licensing received an Unusual Incident Report (UIR), dated 07/10/2026, indicating that Resident (R1) eloped from the secured memory care unit at approximately 9:15 PM. LPA interviewed Staff (S1), who stated they heard the door alarm sound and immediately responded to the front entrance. Upon arrival, S1 observed two residents pushing on the front entrance door. S1 stated the two residents then turned around and walked back toward the lobby area. At that time, S1 did not observe R1, who had already exited the facility. S1 further stated that a nearby neighbor contacted the facility at approximately 10:04 PM to ask whether R1 was a resident of the facility after observing R1 outside. According to the UIR, staff responded to the location, returned R1 to the facility, and the licensed nurse completed an assessment. No injuries were reported. LIC809-C Continued... During today's visit, LPA obtained copies of R1's Physician's Report, Individual Service Plan dated 05/25/2026, and the July 2026 staff schedule. LPA reviewed R1's Physician's Report, which documents that R1 is unable to leave the facility unassisted. LPA also reviewed R1's Individual Service Plan, which states that R1 is to be closely observed whenever outside of the secured memory care area. Deficiencies were observed and cited pursuant to California Code of Regulations, Title 22 (see LIC 809-D). Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Jul 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 31, 2026

87468.2 (a)(4) 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: (4) To care, supervision, and... are delivered by staff...to meet their needs. Based on record review and interview the licensee did not comply with section above by not ensuring care and supervision when R1 eloped during the night and later found by a neighbor who called the facility to ask if R1 was a resident which poses an immediate Health & Safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: The Administrator agreed to conduct an in-service training for all staff on managing resident wandering and elopement. The Administrator will submit a copy of the training lesson outline/synopsis and the staff sign-in sheet to CCLD by the Plan of Correction (POC) due date. Civil Penalty $500.00 assessed today.

Type of visit: Case Management - Health Checks

On 07/09/2026 at 10:30 AM, Licensing Program Analyst (LPA) L. Alexander conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Clinical Director, Maricel Hiponia, and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperatures was measured at 115, 114.1, 109 and 114 degrees F checked in four residents bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Food delivery is on Tuesdays and Fridays. Resident's medications were kept locked in the med room. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 05/29/2026. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. 10:57 am cleaning cart with toxic chemicals left unattended in hallway 12:00 pm S1 has no criminal record clearance on file 12:30 pm facility unable to access residents' and staff records The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 9, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Jul 10, 2026

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:(2) Obtain a California clearance or a criminal record exemption as required by the Department or Based on interview and record review the Licensee did not comply with the section cited above in by having uncleared staff at the facility which poses an immediate health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Jul 9, 2026

Plan of correction: S1 left the facility during inspection. Facility will follow up with Guardian regarding S1's fingerprint clearance and send email communication with Guardian to CCLD by POC date. Civil Penalty Assessed $500.00

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(d) · Plan of correction due date: Jul 10, 2026

87506 Resident Records(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Based on interview and record review the Licensee did not comply with the section cited above in by not having access to residents' and staff records which poses an potential health, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 9, 2026

Plan of correction: Administrator will submit requested to documents to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Jul 16, 2026

87309 Storage Space and Accesss (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. Based on observation the Licensee did not comply with the section cited above in by not having ensuring cleaning solutions are unacessible to residents which poses an potential health, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 9, 2026

Plan of correction: Administrator will read the regulation, self certify and conduct a In-Service training with staff. Send sign-in sheet to CCLD by POC due date.

Type of visit: Required - 1 Year

On 01/29/2026 at 12:30 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with , Laura and explained the purpose of the visit. The facility’s fire clearance was approved for capacity of 75 (seventy-five) residents. In which all may be non-ambulatory. Hospice waiver approved for 19 (nineteen) residents. Administrator Certificate #7008812740 expires 07/07/2027. LPA toured the facility with Tracey including but not limited to four (4) residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 74 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 114.2 and 116.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. LIC809-C Continued... LIC809-C (Page 2) LPA reviewed 6 (six) residents records. LPA reviewed 8 (eight) staff records and 8 of 8 have current first aid training and associated to the facility. Emergency Fire Drills were conducted 10/07/2025, 11/05/2025 and 12/04/2025 on all three (3) shifts. Elopement drills were conducted on 10/23/2025, 11/13/2025 and 12/19/2025. Food Service Report was reviewed dated 12/17/2025. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 02/05/2026: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan - Reviewed Liability Insurance - Reviewed No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 29, 2026

Allegation investigated: Staff retained resident requiring a higher level of care. Staff did not adequately manage resident’s behaviors. Staff did not safeguard resident’s personal belongings.

On 11/13/2025 at 3:35 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Executive Director, Tracey Ingleman, to deliver the findings of above allegations. LPA explained the purpose of the visit with Jonathan Centeno, Director of Resident Services. Tracey Ingleman arrived shortly after. During the investigation, the Department obtained the following documents from the facility: Resident Roster, Staff Roster, Dementia Training Calendar 2024, R1’s Admission Agreement, Physician’s Reports (dated 08/14/24 and 11/06/24), Pre-Admission Appraisal (dated 10/22/24), Medication List, R1’s Face Sheet, Doctor’s Orders, Hospice Care Plan (if applicable for Residents R1–R5), Internal Incident Report (dated 10/28/24), and SOC 341 (dated 11/10/24). LIC9099-C Continued.... Unsubstantiated LIC9099-C (Page 2) Allegation: Staff retained resident requiring a higher level of care Finding: Unsubstantiated On 01/13/2025, Licensing Program Analyst (LPA) interviewed Witness 1 (W1), who stated that they began receiving multiple bills from ambulance services and hospital visits that they were unable to pay. W1 reported that they were not the one contacting 911 or sending Resident 1 (R1) to the emergency room (ER). W1 stated that R1 was sent to John Muir Hospital in Concord because R1 “wasn’t listening.” W1 further stated that R1 had been diagnosed with frontal lobe dementia, which required a higher level of care than what the facility could provide. W1 further stated that when R1 went to John Muir Walnut Creek he was sent back to the facility on hospice because they think the "idea to not send him back and that John Muir doesn't want to keep seeing him constantly." W1 stated that R1 was only on two types of meds and once he got on hospice, seven more types of medications were added. LPA reviewed R1’s Physician’s Reports (dated 08/14/2024 and 11/06/2024), which indicate a diagnosis of possible frontotemporal dementia, with additional notes reflecting behavioral disturbance and advanced dementia, respectively. Record review showed a change in R1’s condition, with documentation of increased confusion, disorientation, refusal or forgetfulness in following instructions, and episodes of aggressive behavior. The Pre-Admission Appraisal (dated 10/22/2024) notes “Higher level of care” for Question #1. Despite these findings, the overall Care Plan identifies R1 as mostly independent in activities of daily living. LPA reviewed that 911 was called 10/28/24 and 11/10/24 per internal incident reports. LIC9099-C Continued... LIC9099-C (Page 3) Allegation: Staff did not adequately manage resident’s behaviors Finding: Unsubstantiated On 01/13/2025, LPA interviewed W1, who reported that R1 exhibited aggressive and inappropriate verbal behaviors, including racial slurs and profanity directed at W1, their pet, and neighbors. W1 stated that R1’s behaviors were difficult to manage and that facility staff—many of whom were students—should have been better trained to address dementia related behavioral issues. W1 stated that despite these ongoing behavioral challenges, the facility repeatedly sent R1 to the emergency room instead of implementing effective behavior management interventions or arranging a more appropriate level of care. LPA reviewed the staff “2024 Annual Veteran Training Calendar.” (updated October 31, 2024). The training calendar shows courses on Resident Rights and Elder Abuse (in relation to Dementia), Dementia: Positive Approach and Dementia: Leading Causes of Expressions and How to Respond as examples. Allegation: Staff did not safeguard resident’s personal belongings Finding: Unsubstantiated During interviews, W1 stated that R1’s missing blanket was later located. There was insufficient evidence to determine that the facility failed to safeguard R1’s personal belongings. 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 allegations is UNSUBSTANTIATED. No deficiencies were cited during today’s visit. An exit interview was conducted with Executive Director, Tracey Ingleman and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 13, 2025 · control 15-AS-20250108111242

Allegation investigated: Staff member handled resident in care in a rough manner. Licensee does not ensure that required information is in areas of the facility accessible to residents,

On 11/10/2025 at 1:50 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Director of Resident Services (DRS), Jonathan Centeno, to deliver the findings of above allegations. LPA explained the purpose of the visit with DRS. During the course of the investigation, the Department obtained the following documents from the facility: Resident Face Sheet, Physician’s Report, Admission Agreement, Pre-Admission Evaluation, Pharmaceutical Services, Carlton Incident Reports, and a Staff Written Statement. LIC9099-C Substantiated LIC9099-C (Page 2) Allegation: Staff member handled resident in care in a rough manner. Finding: Substantiated Investigation revealed that Witness 1 (W1) stated Resident 1 (R1) has possible frontal lobe dementia with behavioral challenges. On 11/10/2024, R1 became agitated and began yelling racial slurs toward Staff 1 (S1) and threatening to kill staff. W1 reported that R1 would not calm down, and S1 placed their hand over R1’s mouth in an attempt to stop R1 from yelling. On 11/21/2024 LPA interviewed S2 that stated R1 was yelling racial slurs at S1. S1 attempted to try to calm the matter and S1 covered R1’s mouth and then later called the police. S1 stated that R1 was placed on leave and later terminated after their internal investigation. Allegation: Licensee does not ensure that required information is in areas of the facility accessible to residents, representatives, and the public. Finding: Substantiated Investigation revealed that W1 stated the ombudsman contact poster was missing from the facility. LPA’s observation confirmed that the ombudsman contact information poster was not posted in an area accessible to residents, representatives, and the public. S1 stated that R1 had torn the poster down from the wall. LIC9099-C (Page 3) Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 10, 2025 · control 15-AS-20241120095158

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Nov 17, 2025

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: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when S1 placed their hand over R1’s mouth while R1 was agitated. This conduct violates the resident’s personal rights and poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 10, 2025

Plan of correction: Licensee shall ensure all staff receive training regarding residents’ personal rights, including techniques for de-escalation and appropriate interventions for residents exhibiting behavioral challenges. Proof of training shall be submitted to the Department by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Nov 17, 2025

CCR 87211(a)(1)(A) – Reporting Requirements Each licensee shall ensure that required information, including contact information for the Licensing Agency, Ombudsman, and other public resources, is posted in areas accessible to residents, representatives, and the public. This requirement is not met as evidenced by: During the visit, the licensee did not comply with the section cited above when LPA observed that the ombudsman contact poster was missing from the facility’s common area This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 10, 2025

Plan of correction: Licensee shall immediately replace the missing ombudsman contact poster in an area accessible to residents and visitors. Licensee shall submit photographic proof of posting to the Department by POC due date. LPA observed Ombudsman poster was posted in the hall entrance. Deficiency cleared during visit.

Type of visit: Case Management - Other

On 11/10/2025 at 1:15, Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit pertaining to a citation issued on January 29, 2025, during an Annual Inspection. The section cited was 87463(h). The citation was appealed and granted at the second level. However, it was determined that a violation did occur and that the correct regulation for the deficiency found is 87463(h)(1). LPA L. Alexander met with Director of Resident Services, Jonathan Centeno, and explained the purpose of the visit. The original citation has been rescinded and, on this day, 11/10/25, the deficiency is recited per the attached LIC809D form from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview was conducted with Director of Resident Services. A copy of this report and Appeal Rights were provided to Jonathan Centeno.the state’s words, verbatim · CDSS document, Nov 10, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(h)(1) · Plan of correction due date: Nov 17, 2025

87463 Reappraisals (h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in by not having an updated annual medical assessment for R1-R4 which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 10, 2025

Plan of correction: Administrator agreed to submit updated LIC 602-A for R1-R4 to CCLD by POC due date.

Type of visit: Case Management - Incident

On 03/07/2025 at 10:15 AM, Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding incidents that was reported to Community Care Licensing Division (CCLD) on 03/02/2025. LPA met with Laura-Anne Leake-Mosley, Executive Assistant, and explained the purpose of the visit. Executive Director, Erica Diala, was not available but arrived around 11:35 AM. LPA interviewed (via phone) staff (S) S1 and S2 that witnessed the incident that took place on 03/02/2025 with resident (R) R1 and R2. S1 and S2 stated that they heard a loud scream coming from one of the rooms and they both went towards the loud noise. S1 stated that they both saw R1 slapping R2 with a plastic hanger. S1 and S2 stated that other caregivers came to assist. S1 and S2 stated that R1's responsible party was phoned and they also called 911 to which the Pleasant Hill Police Department (PHPD) was called and Emergency Medical Technicians (EMT) arrived. S1 and S2 stated that R1 did a FaceTime call with daughter and then they became calmed down. LPA interviewed S3 and S4 regarding another incident that was reported to CCLD on 03/02/2025. The incident occurred on 03/01/2025 between R1 and R3 where community cameras captured video of R1 punching R3 in the shoulder. LPA reviewed the video with S4 and observed R1 punch R3 in the hallway. R3 fell to the floor and caregivers immediately responded to the incident. S3 stated that R1's and R3's responsible parties were called as well as PHPD and EMT to check R1's and R'2 baseline. S3 stated that R3's responsible party declined for R3 to be transported to Emergency Room. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 7, 2025

Type of visit: POC

On 03/07/2025 at 11:30 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Plan of Correction (POC) visit. LPA met with Laura-Anne Leake-Mosley, Executive Assistant, and explained the purpose of the visit. Executive Director, Erica Diala, was not available but arrived around 11:35am. On 01/29/2025, LPA conducted an Annual Inspection visit in which deficiencies were cited. The POC due date was 02/26/2025. Administrator failed to submit the POC by the due date and this is why LPA came to make a POC visit. Deficiencies not cleared: 87411(c)(1) $100 X 9 days = $900.00 During visit Laura gave copies of First Aid/CPR certificates for staff (S) S1 and S2. Deficiency cleared on 03/07/2025. Civil Penalties in the total amount of $900.00 is assessed today for failure to meet POC date for deficiencies. Exit interview conducted. A copy of this report, appeal rights provided and LIC421FC provided.the state’s words, verbatim · CDSS document, Mar 7, 2025

Type of visit: Required - 1 Year

On 01/29/2025 at 11:30 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Erica Diala and explained the purpose of the visit. The facility’s fire clearance was approved for capacity 75 non-ambulatory. Hospice waiver for Nineteen (19) residents. Administrator Certificate #6069844740 expires 05/08/2026. LPA toured the facility with Erica including but not limited to five (5) residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 73 and 74 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 105 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. LPA reviewed thirteen (13) residents records. LPA reviewed sixteen (16) staff records and fourteen (14) of sixteen (16) have current first aid training and associated to the facility. LIC809 Continued.... LIC809-C Continued... The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 02/05/2025: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan (All 9 pages) Liability Insurance Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 29, 2025

Type of visit: Case Management - Other

On 11/21/2024 at 12:15 pm, Licensing Program Analyst (LPA), L. Alexander arrived unannounced to conduct a case management visit. LPA met with Administrator, Erica Diala and explained the reason for the visit. While LPA was conducting a complaint investigation, #15-AS-20241120095158, on 11/21/2024, LPA observed during record review and interview with S1 and S2 that they did not submit an incident report to Licensing for incidents including residents' hospitalizations. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided..the state’s words, verbatim · CDSS document, Nov 21, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: Dec 5, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: This requirement is not met as evidenced by: Based on record review and interview with Staff, the licensee did not comply with the section cited above in by not submitting incident reports including but not limited to hospitalizations to Licensing for residents in care which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 21, 2024

Plan of correction: Administrator agreed to submit a detailed plan on how they will use proper procedures to inform and notify CCLD and will submit plan to CCLD by POC due date.

Type of visit: Case Management - Incident

On 05/30/2024 at 3:45 PM Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 04/26/2024. LPA met with Administrator, Erica Diala and Director of Resident Services Jonathan Centeno and explained the purpose of the visit. LPA L. Alexander interviewed S1 regarding the incident that occurred on 04/24/2024 between two (2) residents; R1 and R2. S1 stated that R1 was walking in a room and R2 was walking right behind R1. S1 stated that R2 was pulling on R1 from behind and R1 turned around and pulled a punch onto R2's face. S1 stated that both R1 and R2 fell to the floor and that R2 hit the back of their head on the floor. S1 stated that care staff and med techs came to help get both R1 and R2 off the floor. S1 stated that R1 said that they did not have pain but R2 said that they had pain so they sent R2 to the Emergency Room. S1 stated that R2 returned back to the facility the same day after all exams and testing came back negative. S1 and S2 stated that both R1 and R2 are ok today and no further issues. LPA L. Alexander collected documents pertinent to the incident report. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 30, 2024

Type of visit: Required - 1 Year

On 01/19/2024 at 10:30 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Evelyn Jensen and explained the purpose of the visit. The facility’s fire clearance was approved for capacity 75 non-ambulatory. Hospice waiver for Nineteen (19) residents. Administrator Certificate#6046038740 expired 11/08/2023. LPA toured the facility with Evelyn including but not limited to 3 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 106 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. LPA reviewed 6 residents records. LPA reviewed 8 staff records and 1 of 8 have current first aid training and associated to the facility. LIC809 Continued.... LIC809-C Continued... The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 01/26/2024: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan (All 9 pages) Liability Insurance Updated Facility Sketch Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 19, 2024

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.