Menifee Senior Living

Allegation investigated: Staff sexually abused resident. Staff handled resident in a rough manner.

Licensing Program Analyst (LPA) Yolanda Delgado conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA Yolanda Delgado met with Rance Leth and explained the reason for the visit. On 10/04/2025, the Riverside Adult and Senior Regional Office (RO) received a complaint regarding allegations Staff sexually abused resident and staff handled resident in a rough manner. It was reported that Staff #1 (S1) arrived to give Resident #1 (R1) a bed bath on 9/23/2025 and a bed bath on 9/25/2025 and S1 rubbed R1’s clitoris. On 9/7/2025 and 9/8/2025 Staff #2 improperly tried to pull R1 out of bed, injuring R1’s shoulder. Regarding the allegation that “staff sexually abused resident” It was reported that Staff #1 (S1) arrived to give Resident #1 (R1) a bed bath on 9/23/2025 and a bed bath on 9/25/2025 and S1 rubbed R1’s clitoris. Facility records revealed that S1 was not assigned to R1’s room and the floor on the dates alleged by R1. (Continued on Page 2) Unsubstantiated (Continued from Page 1) Shower logs and staff assignments records reflect that S1 did not provide care, including bathing assistance to R1 on the alleged dates. Documentation shows that R1 refused a scheduled shower on 9/23/2025 when assigned staff attempted to provide care. A review of records revealed no injuries or findings consistent with sexual abuse, and no evidence, witness statements, or independent information were obtained to corroborate the allegation. Interviews with facility staff and residents, including R1 and R1’s family members, there is insufficient evidence to support the allegation of sexual abuse. Regarding the allegation Staff handled resident in a rough manner. It was reported that Staff #2 (S2) on 9/7/2025 and 9/8/2025 S2 improperly tried to pull R1 out of bed, injuring R1’s shoulder. Facility records revealed that S2 did not work on 9/7/2025 and 9/8/2025, a review of medical records for R1 had a fall on 9/1/2025 at 0400 hours at the facility and was treated at the ER for Right foot fracture; left ankle sprain while attempting to ambulate to the bathroom. On 9/7/2025 R1 had an Emergency Room follow-up related to severe diarrhea. Interviews conducted with staff, residents, including R1 did not corroborate the allegation that staff handled R1 in a rough manner. Records further reflect that R1 experienced a significant decline in physical and cognitive condition during the relevant period, including multiple falls, decreased mobility and neurological complications requiring a higher level of care. Based on the inconsistencies in R1’s statements, lack of corroborating evidence, absence of physical findings, and the documented staff assignments, the allegations is deemed Unsubstantiated. The preponderance of evidence standard has not been met. Therefore, the above allegations are found to be Unsubstantiated. An exit interview was conducted with Rance Leth and a copy of this report along with LIC811- Confidential Names list was provided.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 18-AS-20251004210911

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility Business Manager with LPA identification and business card. Resident record review began- Five (5) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. Employee records review began- Five (5) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current; expires 05/22/2026. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 110.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in their designated areas. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects inside kitchen. LPA verified there is a telephone working at this location. (Continued from LIC809, Page 2) (Continued from LIC809, Page 1) Food Service- Food supply meets the of one week supply of nonperishable and 2-day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation, and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors are tested and found to be operational annually by vendor Fire Alliance Inc. and last inspected on March 27-28, 2025 and a re-test on 04/21/2025. Fire extinguishers are tested or replaced annually and were last done so on 4/4/2024. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 06/24/2025. LPA observed a pool and spa surrounded by a 5 foot secured/locked iron-gate and maintenance is done weekly. Based on the information received during this visit today, there are no deficiency is being cited per Title 22, Division 6 of The California Code of Regulations. An exit interview was conducted were this report was reviewed with Vanessa and a copy will be emailed and a confirmation of receipt will be requested.the state’s words, verbatim · CDSS document, Jun 30, 2025

Allegation investigated: Neglect/Lack of Supervision resulting in resident sustaining injuries. Staff failed to seek timely medical attention after resident's fall Staff failed to notify authorized representative of resident's fall

On 4/29/2025, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to the facility to deliver findings of an investigation into the allegations listed above. LPA met with Administrator, Rance Leth who was informed of the purpose of the visit. The investigation consisted of interviews conducted and records reviewed. A review of R1’s admission agreement indicates R1 was admitted to the facility on 12/22/2022. A review of R1’s Physician’s Report dated 12/20/2022 indicates the categories, ‘able to communicate needs’, ‘able to bathe, dress/groom, and feed self’, ‘able to care for own toileting needs’, marked as 'yes', and ‘requires continuous bed care’ marked as 'no'. The Physician’s Report also indicates R1 is non-ambulatory and able to independently transfer themselves to and from the bed. A review of R1’s Preplacement Appraisal Information dated 12/22/2022 notes R1 exhibited short term memory loss, does not use any ambulation devices, is able to communicate their needs and walk without any physical assistance. A review of R1’s AL Advantage-Assisted Living Resident Assessment dated 12/22/2022 notes the “Status Checks” category is circled “4x per shift”. A review of R1’s Advance Health Care Directive dated 3/15/2018 lists two (2) individuals to serve as Power of Attorney (POA) agents that may act together or separately. Unsubstantiated LPA reviewed three (3) unsigned Unusual Incident/Injury Reports (UI/IRs) regarding R1. The UI/IRs have a date on the bottom left corner stating “5/1/2023” and note the following. On 1/25/2023, R1 had a witnessed fall in the activity room. R1 was assessed, did not have any visible injuries, hit their head, or complain of pain. R1’s “R/P” and “PCP” were notified. The “Medical Treatment Necessary?” section is marked “No”. On 3/30/2023, R1 reported they felt dizzy which caused them to lose their balance and fall onto their buttocks. R1 was assessed for injuries and was observed with redness to their lower back. There were no other visible injuries or complaints of pain. R1’s “PCP” and family were notified. The “Medical Treatment Necessary?” section is marked “No”. On 4/7/2023, R1 reported on 4/5/2023 they fell in the restroom after losing their balance. R1 was assessed for injuries and reported mild left inner thigh pain. R1 denied hitting their head and staff did not see any visible injuries. R1’s “PCP” and family were notified. Family has since taken resident to urgent care for an x-ray and no fractures were found. The “Medical Treatment Necessary?” section is marked “No” and states “Resident was evaluated in urgent care”. A review of the facility’s Narrative Charting noted the following. On 1/25/2023 at approximately 7:30 p.m., R1 was sitting in a chair in the activity room and fell to their knees while attempting to stand up. R1 was able to get up by themselves and the fall was witnessed by staff. R1 did not hit their head, have any visible injuries, complain of pain, and the responsible person was notified. R1’s service plan will be reviewed/updated and “f/u with PCP”. On 3/30/2023 at approximately 7:00 a.m., R1 reported feeling dizzy earlier in the morning which caused them to lose their balance, hit their back on their dresser, and fall onto their buttocks. R1 denied hitting their head or having any pain. Staff assessed R1 for injuries and observed redness to R1’s lower back. Family was also notified. R1’s service plan will be reviewed/updated and “f/u with PCP”. On 4/7/2023 at approximately 7:00 a.m., R1 reported falling on 4/5/2023 at around 5:00 a.m., while attempting to get onto the toilet. R1 complained of mild pain to their inner left thigh. R1 denied hitting their head and staff did not see any visible injuries. Family has since taken resident to urgent care and no fractures were found. R1’s service plan will be reviewed/updated, “f/u with PCP”, and “PT/HH requested for recent falls”. Regarding the allegation, “Neglect/Lack of Supervision resulting in resident sustaining injuries” it was alleged R1 sustained fractures from experiencing unwitnessed falls in the facility. Staff 1 (S1) was interviewed and reported the following information. R1 had two (2) unwitnessed and one (1) witnessed fall while residing in the facility. During the unwitnessed falls, R1 was able to get up by themselves and did not notify staff until later during the day. R1 was assessed and did not have any visible injuries or change of condition and did not complain of severe pain, only soreness. Staff checked on R1 every two (2) hours due to R1 being a fall risk. On 4/7/2023, R1 complained of pain and the facility gave R1’s family the option to transport R1 to urgent care or have staff send R1 out. R1’s family chose to transport R1 to urgent care. R1’s family reported R1 received x-rays, but nothing was found and R1 returned to the facility with no medication orders. R1 was referred to physical therapy due to their recent falls. R1 was reportedly taken to urgent care on 4/7/2023 after experiencing a fall in the facility. A review of R1’s medical records from Accelerated Urgent Care indicated R1 complained of bilateral hip pain and had been falling at approximately 4:00 a.m., while getting to the bathroom. The urgent care medical records stated, “There is no evidence for acute fracture. However, please note that in elderly patients a fracture may be occult and difficult to exclude with certainty by X-ray evaluation. To exclude an underlying subtle or occult fracture with certainty further evaluation with MRI is recommended.” A review of R1’s medical records from Loma Linda University Medical Center Murrieta noted on 4/21/2023, R1 was taken to the emergency room due to leg pain and having an unwitnessed fall on 4/5/2023. Medical records note R1 was taken to urgent care on 4/7/2023 and received back and hip X-rays and no abnormalities were noted. Medical records also note R1 received a CT scan of the left hip which showed fracture of superior and inferior pubic ramus as well as compression fracture of L5 vertebrae which appeared consistent with the cause of R1’s reported pain. Regarding the allegation, “Staff failed to seek timely medical attention after resident's fall” it was alleged the facility neglected to seek medical attention for R1 after the falls. An interview with two (2) additional staff was conducted who reported it is the facility’s protocol to activate emergency medical services when the facility learns a resident experienced an unwitnessed fall in the facility. However, LPA reviewed the facility’s program outline, and the “Medical Emergency” section notes the following. It is the facility’s policy to summon emergency medical services when a resident exhibits signs and systems of distress and/or emergency condition including a fall with deformity, severe pain or head injury. Non-emergency transport is only used when the resident needs urgent but non-emergency medical care, such as stitches, controlled bleeding, etc. The Resident Care Director or medication technician on duty is to contact the resident’s family/responsible person as quickly as possible, once the resident is safely under the care of the paramedics. Additionally, the UI/IRs and Narrative Chartings documented R1 was assessed, did not complain of severe pain, head injury, or sustained a fall with deformity. One (1) of three (3) staff interviews conducted reported residents were checked on at least every hour during the nocturnal shift and additionally, as needed, if staff heard any unusual noises. One (1) of three (3) staff interviews conducted reported R1 constantly walked around in the facility and remained in their line of sight during day hours. R1 was interviewed and reported staff were always around. R1 was unable to recall if staff checked on them throughout the day. R1 reported they informed staff they were “fine” and requested staff leave them alone. LPA also made several unsuccessful attempts to conduct an interview with four (4) additional staff reportedly present during the alleged incident time-frames. The Department did not receive an additional care plan outlining a focus to prevent/reduce the risk of R1 falling. Regarding the allegation “Staff failed to notify authorized representative of resident’s fall” it was alleged the facility did not notify R1’s responsible person of two (2) of R1’s falls. The UI/IRs and Narrative Chartings documented R1’s “R/P”/family were notified after the falls. However, a witness interview was conducted with one (1) of R1’s healthcare POA agents who identified themselves as the main point of contact between R1’s family/POA agents and facility staff. The witness reported the facility informed them about the 1/25/2023 fall R1 experienced in the facility. The witness added R1 called them from their cellphone and informed them they experienced a second fall in the facility on approximately 3/30/2023. The witness does not know if R1 reported the second fall to facility staff. The witness reported they notified facility staff of R1’s second fall. The witness also reported R1’s family member visited R1 in the facility in April 2023 and informed facility staff they believed R1 required a medical evaluation due to having leg pain. The witness reported facility staff called them to notify them of the new information received. The witness reported on approximately 4/12/2023, R1 was removed from the facility and in the care of their family and taken to the hospital for further evaluation on 4/21/2023. During S1’s interview, they also confirmed R1 was removed from the facility on 4/12/2023 and in the care of their family. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this entire report and Confidential Names list (LIC 811) was reviewed and provided to Administrator Leth.the state’s words, verbatim · CDSS document, Apr 29, 2025 · control 18-AS-20230428143402

Type of visit: Case Management - Deficiencies

On 4/29/2025, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to the facility to address a deficiency discovered during a complaint investigation involving Resident 1 (R1). LPA met with Administrator, Rance Leth who was informed of the purpose of the visit. On 5/1/2023 from approximately 12:50 p.m. to 2:30 p.m., the Department conducted the initial complaint visit to obtain pertinent records regarding complaint control number 18-AS-20230428143402. Records obtained included three (3) Unusual Incident/Injury Reports (UI/IRs) documenting a total of three (3) falls on 1/25/2023, 3/30/2023, and 4/5/2023 that R1 experienced while residing in the facility. The UI/IRs are not signed and the “REPORT SUBMITTED BY:” and "REPORT REVIEWED/APPROVED BY:" date sections are blank in all three (3) UI/IRs. The UI/IRs have a date and time on the bottom left corner stating “5/1/2023 1:42:24 PM”, “5/1/2023 1:43:35 PM” and “5/1/2023 1:44:23 PM”. LPA reviewed the Community Care Licensing (CCL), Riverside Regional Office’s incident report/duty log and there is no record the facility submitted any UI/IRs for R1 while they resided in the facility from December 2022 to April 2023. In addition, during an interview conducted with Staff 1 (S1) they reported staff write incident reports and they only report to CCL if the resident experienced a head injury or went to the hospital. S1 added it depends on the circumstances whether or not they report the incident to the State. Based on the totality of the circumstances, the facility will be cited for not meeting the reporting requirements pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, Regulation 87211. An exit interview was conducted and a copy of this report Confidential Names list (LIC 811), LIC 809-D, Appeal Rights were reviewed and provided to Administrator Leth.the state’s words, verbatim · CDSS document, Apr 29, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: May 13, 2025

(a)(1)(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by: During investigation of a complaint, the Department received three Unusual Incident/Injury Reports (UI/IRs) documenting a total of three (3) falls 1/25/2023, 3/30/2023, and 4/5/2023 that R1 experienced while residing in the facility. LPA reviewed CCL's incident report/duty log and there is no record the facility submitted any UI/IRs for R1 to report the falls. This poses a potential health, safety, and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 29, 2025

Plan of correction: Administrator, Rance Leth reported the facility will conduct an in-service staff training regarding reporting requirements. Proof of correction to be submitted to LPA by close of business on 5/13/2025.

Allegation investigated: Staff do not treat resident with dignity and respect

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit related to the allegations listed above. LPA initially met with facility staff and explained the reason for today’s visit. LPA met with Executive Director Rance Leth at 09:56AM. Entrance interview conducted. During today's visit, LPA interviewed 6 (six) residents and 6 (six) staff between 09:25AM – 09:40AM and 10:17AM to 02:45PM, interviewed R1’s private caregiver, interviewed R1’s family member telephonically and obtained and reviewed copies of relevant documents. During an initial complaint visit conducted by LPA Cheryl Goodrich on 12/06/2023, LPA Goodrich toured the facility, interviewed residents and staff, and collected pertinent documents. During a subsequent complaint visit conducted by LPA Kathleen Banrasavong on 03/27/2024, LPA conducted a tour, reviewed and obtained documents, and interviewed residents and staff. Throughout the course of the investigation, LPA Dulek reviewed all documents gathered. The following was then determined: Report Continued on LIC 9099-C Substantiated The complaint alleges that Staff #1 (S1) bullies Resident #1 (R1) in an “angry way.” Reporting party indicated that after discussing the concerns about R1 to S1’s supervisor, S1 was not to provide care to R1 any longer, however S1 continued to enter R1’s room and demanded R1 shower. LPA reviewed R1’s care plan and physician’s report, both of which indicate R1 requires assistance with activities of daily living (ADLs) including assistance washing R1’s hair and body, assistance with dressing and grooming. R1’s care plan does indicate bathing on pm shift with a note indicating “7PM. Would like 3 showers weekly.” LPA Dulek interviewed staff related to the allegation. Staff indicated there is a shower schedule and the care staff provide showers per the schedule. S1 works the pm shift, so S1 would have been responsible for showering R1 at times. Staff interviewed stated that many care staff, including S1 talk to R1 regularly and share personal information with R1. At the time of the complaint and ongoing since, staff have continued to share information with R1 and have had personal disputes amongst the staff, which have been discussed with R1. Management is aware of the ongoing concern and have held meetings addressing professionalism in the workplace. Staff interviewed have heard from residents that staff have been rude towards the residents, including R1. 4 (four) of 6 (six) residents interviewed indicated that there have been staff in the past around the time of the complaint as well as current staff that have yelled and been intimidating towards the residents. Based on interview and record review, the preponderance of evidence standard has been, therefore the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency is cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report was provided. The complaint alleges that R1 was given a pill, which R1 did not recognize and caused R1 to become tired and lowered R1’s heartrate. R1 questioned Staff #2 (S2) about the unrecognized medication, but S2 indicated the medications were all correct. LPA reviewed R1’s Medication Administration Record (MAR) and cross referenced R1’s physician’s ordered medication list. LPA confirmed that all medications listed on the MAR have been ordered by R1’s physician. R1’s physician’s report does indicate R1 was able to store and administer their own prescription and PRN medications, however R1’s care plan indicates R1 was on medication management at that time. R1 and their family member stated R1 was taken to the hospital as a result of low heart rate. LPA reviewed incident reports for the time frame referenced in the complaint, but no incident reports were submitted relating to R1 being hospitalized, nor were there any care notes entered or other documentation to reflect outside care was needed. Interview with S2 revealed that R1 did not ask about their medications during the time of the alleged error and all medications were administered to R1 as prescribed. All other residents interviewed indicated their medications are administered on time and as prescribed. LPA confirmed R1 is no longer on medication management with the facility and is instead storing their own medications at this time. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No citations issued related to the above allegation. Exit interview conducted. A copy of today’s report was provided.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 18-AS-20231129162111

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 6, 2025

87468.1 Personal Rights of Residents in All Facilities (a) (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the above cited section as 4 of 6 residents interviewed and staff corroborated that staff share personal information with residents and staff are rude to residents which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 22, 2025

Plan of correction: Executive Director agreed to conduct a vendorized training with all staff related to personal rights of residents. A copy of the training documents including trainer, date, staff sign in and materials will be submitted to CCL by POC due date.

Allegation investigated: Staff do not ensure adequate care and supervision is provided to resident Staff is not addressing resident’s need for a higher level of care

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit related to the allegations listed above. LPA initially met with facility staff and explained the reason for today’s visit. LPA met with Executive Director Rance Leth at 09:56AM. Entrance interview conducted. During today's visit, LPA interviewed 6 (six) residents and 6 (six) staff between 09:25AM – 09:40AM and 10:17AM to 02:45PM and obtained and reviewed copies of relevant documents. During an initial complaint visit conducted by LPA Venus Mixson on 05/09/2024, LPA Mixson toured the facility, made observations pertaining to the allegations and received copies of pertinent documents. On 12/11/2024, LPA Yolanda Delgado conducted a subsequent complaint visit. LPA Delgado interviewed Administrator and 6 (six) staff and obtained copies of pertinent documents. Throughout the course of the investigation, LPA Dulek reviewed all documents gathered. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegation: “Staff do not ensure adequate care and supervision is provided to resident:” The complaint alleges that Resident #1 (R1) screams for help and has fallen while at the facility. Record review revealed that R1 had moved into the facility on 11/22/2023 and shared a room in the Assisted Living side of the facility with their spouse. R1’s care plan upon admission included status checks, which were documented in the resident’s narrative charting. R1’s spouse moved out of the facility on 12/30/2023 and R1 continued to reside in the room in Assisted Living. On 02/16/2024, a new care assessment was completed for R1, which continued to indicate status checks for R1 were necessary. Incident reports reviewed revealed R1 was found on the floor on multiple occasions, but R1 was uninjured and refused to be sent to the hospital. Additional incident reports indicate that on 05/06, 05/07, and 05/09/2024, R1 refused or missed medications. R1’s physician and family were notified of the medication refusals. On 05/10/2024, R1 was moved to the memory care unit at the facility. Interview with staff revealed that the resident was receiving hospice care the entire time R1 resided at the facility; hospice aide provided bathing assistance to R1. Care staff was responsible for the remainder of R1’s ADL care, including but not limited to: assistance with dressing, grooming, and incontinence care. Staff stated staff checked on R1 every 2 (two) hours, as R1 was a potential fall risk and required regular incontinence care. Staff also stated R1 had a motion mat next to their bed that would alert staff when R1 was getting out of bed and after the mat was placed and the staff rearranged the furniture in R1’s room, R1 had less falls. Residents interviewed throughout the complaint investigation stated their care needs are met, and staff provide sufficient supervision. When R1 moved out of the facility, R1’s family member wrote a letter indicating “we were happy with the experience at Pacifica” and the move was to be closer geographically. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. Allegation: “Staff is not addressing resident’s need for a higher level of care:” Record review revealed that upon moving into the facility, that R1 was identified as a level 7 for care, including status checks and 2-person assist for most ADL (activity of daily living) care. At that time, R1 was also receiving hospice services. R1’s physician’s report dated 11/20/2023 indicates R1 has a diagnosis of Alzheimer’s Dementia and hypertension, R1 can feed themselves, but required assistance with all other ADL Report Continued on LIC 9099-C care. R1’s physician did not indicate R1 wanders or has aggressive or inappropriate behavior. Upon reassessment on 02/16/2024, R1 was lowered to a level 5 care. Narrative charting for R1 indicated R1 refused medications on 3 (three) dates in May, as identified in the report above. R1 was then moved to the facility’s memory care unit on 05/10/2024 and a new care assessment was completed. R1 was lowered again to a level 4 care. LPA interviewed staff and management related to the complaint allegation. Interviews revealed that R1 did yell for assistance and staff stated this is not an uncommon behavior. When a resident is observed to have additional behavioral expressions or could potentially require a change in care, care staff will report to the med tech or a supervisor and a nurse will assess the resident. Then the facility communicates with the family to ensure the resident’s needs are met and consistency of care for the resident. In the case of R1, facility management was communicating with R1’s family member to arrange the finances and care as R1’s dementia progressed. R1 was moved to the memory care unit when the nurse and family agreed was appropriate for R1. R1’s family member then moved R1 out of the facility on 06/08/2024. While R1 did move to a facility that offers a higher level of care, R1’s family member stated they moved R1 to a facility closer to family and the same facility R1’s spouse was residing at. According to R1’s family member, R1 was moved into the other facility’s memory care unit, which offers the same level of care R1 was receiving at this facility. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. No citations issued. A copy of today’s report was provided.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 18-AS-20240502133223

Allegation investigated: Staff do not ensure that resident is sufficiently fed while in care Staff do not respond to requests for assistance by resident in a timely manner

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit related to the allegations listed above. LPA initially met with facility staff and explained the reason for today’s visit. LPA met with Executive Director Rance Leth at 09:56AM. Entrance interview conducted. During today's visit, LPA interviewed residents and staff between 09:25AM – 09:40AM and 10:17AM to 02:45PM and obtained and reviewed copies of relevant documents. During an initial complaint visit conducted by LPA Yolanda Delgado on 11/22/2024, LPA Delgado interviewed Business Office Manager, two (2) staff, one resident (1) requested and obtained copies of pertinent documentation. Throughout the course of the investigation, LPA Dulek reviewed all documents gathered and conducted additional staff interviews telephonically. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegation: “Staff do not ensure that resident is sufficiently fed while in care:” The complaint alleges that Resident #1 (R1) was not provided any meals on 11/16/2024. R1 stated on this date, they were experiencing leg pain and chose not to leave their room for meals. Interview with R1 revealed that there was a misunderstanding, and no complaint should have been filed. R1 indicated they are able to request meals in their room. However, at the time of the complaint, R1 did not request a meal, as R1 was not hungry. In another statement, R1 indicated they had slept through lunch and staff had brought her breakfast that day. Record review revealed that R1’s care assessment dated 10/27/2024, indicates meals – preparation only. According to staff interviewed, R1 prefers to stay in their room and requests meals be brought to their room. Occasionally R1 requests a staff escort to meals by pressing their pendant. Residents interviewed stated they receive all meals in the dining room daily or they can order with the staff and the meals can be delivered to their personal rooms. ED stated the dining room is open from 07:00AM to 06:00PM and residents can eat meals and/or snacks all day long. Care staff do have a checklist of their assigned residents and observe that their assigned residents attend meal service. If care staff do not see a resident at a meal, care staff will follow up with the resident to see if they would like to order a meal. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation "staff do not ensure that resident is sufficiently fed while in care" is deemed UNSUBSTANTIATED at this time. Allegation: “Staff do not respond timely to resident’s request for assistance:” The complaint alleges that on 11/16/2024 R1 pushed their pendant and no staff came to assist. During initial visit, R1’s pendant was tested and staff responded in less than 2 (two) minutes. Interview with staff revealed that there are typically 4 (four) care staff assigned to assist Assisted Living residents during the day. Facility policy states that staff respond to pendants within 15-20 minutes. Interview revealed there are times when the care staff is busy assisting other residents and may take longer to respond, but they still do their best to remain within the appropriate time frame. Care staff also carry walkie talkies and can request another staff to assist if the assigned caregiver is busy assisting another resident. Pendant response system is computerized, however, record retention is for a 30-day period, so LPA was unable to review response records for the date in question. Residents interviewed felt their needs are being met and staff are timely in responding to Report Continued on LIC 9099-C requests for assistance. R1 stated the complaint should never have been filed and most staff assist R1 timely whenever possible. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted with ED. A copy of today’s report was provided.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 18-AS-20241118143654

Allegation investigated: Resident is not provided a sanitized foley bag. Resident was left soiled for an extended period of time.

On 4/22/25 at 8:50 a.m. Licensing Program Analyst (LPA) Melisa Rankin arrived to conduct an unannounced visit to the facility to investigate and deliver the findings regarding the above allegations. The LPA met with Executive Director (ED), Rance Leth, and informed him the purpose of the visit. An initial visit on 9/14/22 by LPA Stephanie Torres was conducted. LPA Torres conducted staff interviews, reviewed records, and took copies of pertinent documentation. On the allegations Resident is not provided a sanitized foley bag and Resident was left soiled for an extended period of time. Unsubstantiated Complaint states the resident presented at the emergency room on 9/3/22 with Foley Catheter pulled out, but a portion still inserted into R1 and that the foley bag was not appropriately placed, was unclean and open to infection. In addition, the resident was covered in feces. Prior to the visit LPA Rankin reviewed staff interviews provided by prior LPA Torres, as well as contacted additional staff interviews via phone calls. Interviews of facility staff done by both LPA’s, as well as records obtained showed R1 had been re-admitted to the facility approximately late afternoon of 9/2/22 after being discharged from a Skilled Nursing Facility (SNF), and all staff interviewed stated, that on the morning of 9/3/22 R1 had either driven over or cut their catheter that was connected to the foley bag causing it to be disconnected. Urine was dripping from the tube which was being dragged around the floor behind R1’s scooter. Staff interviewed and records reviewed stated that R1 was not acting in their usual character, R1 was in the lobby without their shirt, and was slurring words, R1 was confused, and when staff went to R1’s room they smelled urine and noticed feces. Staff called 911 to have R1 transferred due to the foley cather bag needing to be repaired, and the residents change in behavior. Records review showed that R1 had a UTI when admitted to the hospital. The time frame for R1’s stay at the facility was less than 24 hours. R1 was discharged on 9/2/22 from the SNF and the resident was sent out the early afternoon of 9/3/22 from the facility. Based on interviews, and records reviewed. The allegations may have happened or is valid, but there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Copy of report printed and given to Licensee.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 18-AS-20220907084531

Allegation investigated: Staff do not meet a resident's hygiene needs

On 4/22/25 at 8:50 a.m. Licensing Program Analyst (LPA) Melisa Rankin arrived to conduct an unannounced visit to the facility to complete the investigation and deliver the findings into the above allegation. The LPA met with Executive Director (ED), Rance Leth, and informed him of the purpose of the visit. An initial visit on 8/21/24 by LPA Javina George was conducted. LPA George reviewed records and took copies of pertinent documentation. On the allegation Staff do not meet a resident's hygiene needs. Complaint alleges Resident 1’s (R1) hygiene was not good and toenails were long and unkept. Unsubstantiated Prior to arrival LPA Rankin interviewed, via phone conversations, Reporting Party (RP) on 4/18/25 and Staff 1 (S1) on 4/21/25, and reviewed interviews and documentation provided by prior LPA visit. RP stated the complaint was made to RP by the podiatrist at the hospital but had no additional information to provide LPA. During visit LPA interviewed Staff 2 (S2). Staff 2 provided R1’s admit date to the Memory Care unit which was 7/6/24. Interviews of facility staff confirmed that the caregivers do not trim residents’ nails. The facility has a podiatrist that comes every 8 weeks. A list of residents in memory care needing services is provided to the podiatrist. Interview and records reviewed for the time frame of residents admittance into memory care showed the scheduled podiatrist came 7/5/24, prior to resident admittance, and again on 9/5/24. From 8/14/24 to 11/25/24 resident was absent from the facility due to fractured hip. Record for 1/30/25 shows R1 on the list for podiatry care. Based on interviews, and records reviewed. The allegations may have happened or is valid, but there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Copy of report printed and given to Licensee.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 18-AS-20240818221750

Allegation investigated: Resident is reporting ring is missing

On 4/22/25 at 8:50 a.m. Licensing Program Analyst (LPA) Melisa Rankin and Kelly Dulek arrived to conduct an unannounced visit to the facility to deliver the findings of the investigation into the above allegations. The LPA met with Executive Director (ED), Rance Leth, and informed him of the purpose of the visit. An initial visit on 01/27/25 by LPA Yolanda Delgado was conducted. LPA Delgado, conducted interviews, reviewed records and took copies of pertinent documentation. Continued on 9099-C Unsubstantiated On the allegation Resident is reporting ring is missing. Complaint states that on 01/15/25 a caregiver was informed by a resident that a ring was missing from their room. Prior to arrival LPA Rankin interviewed the Responsible Representative (RR), called staff, and reviewed interview records from prior LPA visit as well as the documents collected during the initial visit. Review of these documents noted that Resident 1 (R1) and their RR signed the Resident Personal Property and Valuables (LIC 621) form, but did not list any property. R1 and RR also signed all appraisal, consent forms, and the admission agreement. On the admission agreement there is a theft and loss policy noted. In response to the theft and loss policy the facility documented the allegation, submitted a report to the Ombudsman office, notified Community Care Licensing, and filed a police report. Additionally, the facility notified the RR. LPA Dulek who conducted resident interviews during the visit stated 1 out of 6 residents interviewed stated they had missing items which the resident alleges occurred in the last 2 – 3 weeks, and LPA Rankin interviewed an additional 3 residents in which one stated they had missing items which occurred over 6 months ago. Staff 2 (S2) interviewed stated R1 is very private and meets staff at their door. LPA interviewed the RR on 4/21/25. RR stated they had not seen the ring in question but did state at one point that the RR brought a box of jewelry to R1 at the facility. RR is unsure of how much or what specific items were in the box. Due to R1 and RR not noting the property on the Resident Personal Property and Valuables (LIC 621) form and the facility following the theft and loss policy and based on interviews, and records reviewed. The allegations may have happened or is valid, but there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Copy of report printed and given to Licensee.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 18-AS-20250121133146

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced visit at the facility in conjunction with an investigation of complaint control # 18-AS-20231129162111. During today's investigation, LPA observed deficiencies unrelated to the complaint allegations. During record review, LPA observed that at the time of the alleged medication error (05/19/2023 and 05/20/2023), that Resident #1 (R1)’s metoprolol tartrate 50mg was prescribed “take 0.5 tab (25mg) by mouth twice daily for hypertension only take if heart rate >75.” Staff interviewed indicated that staff do not take resident heart rate readings, as medication technicians are not skilled medical professionals and that residents with parameters in their prescription orders must be able to take their own readings prior to medication administration. Staff interviewed stated that R1 would measure their own heart rate. When the med tech would go to R1’s room to administer medications, the med tech should have asked R1 what their heart rate was and confirm with R1 whether the medication should be administered or held based on R1’s heart rate reading. However, the medication technicians working on 05/19/2023 and 05/20/2023 were not the regular medication technicians at the time of the alleged error. Review of R1’s MAR indicates the medication was administered by one medication technician twice (in the morning on 05/19/2023 and 05/20/2023) and by another staff at night on 05/19/2023. These were the only 3 (three) times the medication was administered at all from May 2023 to November 2023. Interview revealed that staff did not ask R1 what their heart rate was or confirm whether the medication was needed or should be held, as ordered. R1 and their family member recall R1 requiring outside medical attention due to low heart rate following the 3 (three) times this medication was administered, however the facility did not have documentation reflecting this. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, Apr 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 6, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as R1 was given a medication prescribed with parameters without confirmation R1 required the medication, which posed an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Apr 22, 2025

Plan of correction: Executive Director indicated R1 is no longer utilizing facility medication mangement. ED agreed to retrain all staff who administer medications on medication policies and procedures and provide proof of training to CCL by POC due date.

Allegation investigated: Staff do not ensure medications are dispensed as prescribed

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegation. LPA met with Executive Director, Rance Leith, who was informed of the purpose of the visit. The investigation consisted of interviews and records review. It was alleged that “Staff do not ensure medications are dispensed as prescribed” It was alleged Resident#1 (R1) did not receive their PRN medication as prescribed June of 2024. Interview with R1 was unable to be conducted as R1 has since passed away. Interview with R1’s responsible party revealed they were unaware of any medication errors or PRN medication not being given as prescribed. Substantiated Records review revealed no incident reports for medication errors for R1 were documented. Electronic Medication Administration Record (EMAR) for R1 June 2024 revealed R1 had PRN medication prescribed to them which was recorded as given with the reason for giving the medication and the effectiveness of the dose recorded. Interview with (4) med tech staff revealed they were not aware of any medications errors for R1 and stated R1 obtained their PRN medication when needed. It was also alleged Resident #2 (R2) was given their medication twice May or June of 2024. Incident report dated 05/25/2024 revealed R2 was given Medication #1 (M1) twice due to a documentation error. The incident report stated Staff #1 (S1) had given Medication #1 (M1) at 6:00am to R2 and did not document it on the MAR before ending their shift. Another staff gave M1 to R2 after seeing M1 was not documented as given. The resident was placed on alert charting and monitored for any change in condition. Interview with S1 revealed they forgot to document M1 as given to R2 and another staff had given M1 again to R2 due to seeing M1 was not documented. An interview with R2 was unable to be conducted as R2 has since passed away. Interview with R2’s responsible party revealed there was an incident where R2 received M1 twice due to a staff member not properly recording the medication as given. The responsible party stated they were informed of the error and the resident did not suffer any adverse reactions. Therefore, based on LPA’s interviews conducted, and records reviewed the allegation that residents did not get their medication dispensed as prescribed is found to be substantiated for R2's medication error. The preponderance of the evidence standard has been met, therefore the above allegation is found to be substantiated at this time. California Code of Regulations Title 22 is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided. June 2024 Staff Schedule and staff interviews revealed the NOC shift is from 10:00pm to 6:00am and is followed by the AM shift from 6:00am to 2:00pm. Staff interviews revealed residents are checked on every (2) hours unless they require additional checks per their incontinent needs and written assessment. R1’s Resident Assessment dated 06/18/2025 revealed R1 required to be checked on (4) times per shift, which equates to every (2) hours. Staff revealed changing of residents is not documented. An interview with R1 was unable to be conducted as R1 has since passed away. Interview with R1’s responsible party revealed they visited R1 around June of 2024 in the early morning and stated R1 was observed in soiled diaper and clothing occasionally. The responsible party estimated that R1 had not been change in (4) hours. They reported R1’s room was not observed to smell of urine or feces. Interview with (2) NOC shift staff working June of 2024 revealed R1 was never left in soiled clothing or diaper and could not recall a time where R1’s room smelled of feces or urine. LPA interviewed (3) AM shift staff working June of 2024 which revealed conflicting information. (1) staff interview revealed they were unaware of R1 being left in soiled clothing or diaper for an extended period of time or R1’s room being malodorous. (1) staff interview revealed they observed R1 in soiled clothing, sheets, and diaper and R1’s room was malodorous. This staff stated they reported this to the facility nurse Staff #2 (S2). Interview with S2 revealed they did not recall a time when R1 was left in soiled clothing or diaper. Therefore, the allegation that R1 was not changed for an extended period of time and that R1’s room was malodorous is found to be unsubstantiated. It was alleged “Staff do not ensure resident records are properly maintained” It was alleged that the narcotic medication counts for residents were not accounted for and the medication log for narcotic medication was being altered by staff June of 2024. LPA conducted interviews with (4) residents who resided at the facility June of 2024. The residents revealed they were unaware of the medications they were taking or if there were any medication errors with narcotic medications. LPA conducted (2) interviews with responsible parties for residents who resided at the facility June of 2024 who revealed they were unaware of any narcotic medication errors. LPA conducted interviews with (4) med tech staff who worked at the facility June of 2024. Staff interviews revealed narcotic medications are counted by med tech staff every shift and are recorded in the Electronic Medication Administration Record (EMAR) system by the supervising nurse in a narcotics medication Shift Change Log. Staff revealed the EMAR system accounts for any changes or edits made and were unaware of the logs were being altered. Interview with supervising nurse from June of 2024 denied the narcotics medication Shift Change Log was altered and stated all narcotics were accounted for. LPA requested the EMAR Narcotic log for (4) resident who resided at the facility June of 2024. The logs revealed the medication was accounted for every day of June 2024 with no discrepancies or documented changes. Therefore, the allegation that staff are not ensuring the resident’s medication records are maintained is found to be unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 25, 2025 · control 18-AS-20240626140848

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 3, 2025

(a) A plan for incidental medical...care shall be developed by each facility. The plan shall encourage routine medical...care and provide for assistance in obtaining such care... (4) The licensee shall assist residents with self-administered medications as needed. This requirment was not met as evidenced by: Based on interview and record review, R2 received incorrect does of M1 due to staff error. This posed a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 25, 2025

Plan of correction: The Administrator agreed to send medication training for S1 by the POC due date.

Allegation investigated: Facility has mold. Facility roof is in disrepair.

Licensing Program Analyst (LPA Javina George made an unannounced visit to the facility to commence a complaint investigation in regard to the allegations noted above. LPA met with Executive Director Rance Leth and explained the purpose of the visit and the elements of the allegations. The allegations were investigated, which consisted of observations, interviews and records review. On January 25, 2024, Community Care Licensing received a complaint alleging that the facility has mold and that the facility roof is in disrepair. Regarding the allegation of the facility has mold specifically in Resident #1 (R1)s and Resident #2 (R2)s bedroom. On 01/31/24 LPA conducted a tour of the interior and exterior areas of the property. LPA did not observe the presence of mold, or a mold like odor. In addition LPA conducted interviews with facility staff whom denied there being any reports from other staff, visitors or residents reporting that they have physically seen or smelled mold at the facility. In addition per an interview with Maintenance Director Ryan Kolster there was no testing conducted to confirm that there was mold in R1s and R2s bedroom. Per an interview with R1 and R2 the allegation could not be corroborated as R1 and R2 Unsubstantiated denied seeing mold inside their bedroom, and confirmed that there was no testing done in their bedroom for mold. Based on observations, interviews and records review the allegation of facility has mold is unsubstantiated. Facility roof is in disrepair It was alleged that on or around 01/25/24 there was a leak inside the roof in R1 and R2s bedroom. On 01/31/24 LPA conducted the initial 10 day visit to the facility and observed for right corner of the ceiling in the second bedroom in R1 and R2s unit to have been patched with a white temporary replacement tile/cover. Per interviews conducted with R1 and R2 there was a leak and it is in the process of being repaired. Per an interview with Maintenance Director Ryan Kolster the was a leak in the roof in the unit, that was discovered in December 2023, an HVAC Specialist came out and was able to drain the pipe. LPA conducted a records review (email) that revealed the Executive Director Rance Leth was aware of a leak, and had requested assistance with getting the leak remedied from corporate as, the issue was reoccurring. The leak was repaired on 1/22/24 as the drain was sealed the drain from the roof and a drip pan installed. Per an interview with Resident Services Director Rachelle Wheaton both R1 and R2 were offered to move to another unit but declined. Per an interview with R1 they did confirm that they declined to be moved as they like the view from their current unit. R2 reported it was the dripping sound that was the most bothersome. Based on observations, interviews and records review the allegation of facility roof is in disrepair is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted and a copy of this report and LIC 811-confidential names list was reviewed and provided to Executive Director Rance Leth.the state’s words, verbatim · CDSS document, Feb 21, 2025 · control 18-AS-20240125113223

Allegation investigated: Staff member caused an injury to resident.

Licensing Program Analyst (LPA Javina George made an unannounced visit to the facility to commence a complaint investigation in regard to the allegation noted above. LPA met with Executive Director Rance Leth and explained the purpose of the visit and the elements of the allegation. The allegation was investigated, which consisted of observations, interviews and records review. On August 15, 2024, Community Care Licensing received a complaint alleging that a staff member caused an injury (bruising) to resident. It was further alleged that a staff member had grabbed Resident #1 (R1) by the wrist and pinched them. Prior to going out to the facility a file/records review was conducted which revealed the facility submitted an unusual incident/injury report on 08/13/24 reporting R1 to have unexplained bruising. LPA conducted interviews with R1 whom stated and re-enacted how they were grabbed by an unknown staff member and pinched, however did not think that the staff had intent to harm them. In addition, LPA observed for R1 to have a red and purple colored bruise on their left Unsubstantiated wrist measuring about 3" wide. R1 is visually impaired and was unable to provide a description of the staff. Additionally, R1 stated that they do not feel the staff intentionally grabbed them, but it was more a training issue regarding proper lifting techniques. LPA conducted interviews with multiple staff members, who stated that they were not initially aware of the bruising. However, staff verified that once they became aware of the bruising, they questioned R1 and R1 stated that they were grabbed by their wrist and pinched by an unknown staff. R1 is believed to have obtained the injury (bruise) on or around 8/7/24 or 8/8/24. On 08/16/24 facility staff were retrained on proper lifting and transferring post incident. Based on observations, interviews and records review the allegation of staff member caused an injury to resident is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted and a copy of this report and LIC 811-confidential names list was reviewed and provided to Executive Director Rance Leth.the state’s words, verbatim · CDSS document, Feb 21, 2025 · control 18-AS-20240815095433

Allegation investigated: Facility not feeding resident in a timely manner. Staff financially abused resident.

Licensing Program Analyst, (LPA) Yolanda Delgado arrived unannounced to the facility to conclude an investigation pertaining to the allegations listed above. LPA met with Executive Director Rance Leth and explained the purpose of the visit. On April 22, 2022, Community Care Licensing received a complaint alleging facility staff not feeding resident in a timely manner and staff financially abused resident. LPA conducted interviews with Administrator, staff, residents, and additional witnesses. LPA also conducted a review of pertinent documentation. In regards to the allegation that facility is not feeding resident in a timely manner, it was reported that Resident had to wait 2 hours to eat. Information obtained from an interview with Administrator stated food trays can be ordered and would be delivered at the designated times. (Continued on Page 2) Unsubstantiated (Continued from Page 1) Administrator stated the dining area is open daily from 7 am-6 pm; lunch is served from 11-1PM. Administrator stated there were no concerns advised of any resident waiting 2 hours to eat. Interview with Resident Care Director revealed that Resident had meals delivered to their room three times a day for the month of March and April 2022. It was advised that Resident started going to the dining hall to get meals. Interview with Resident stated that they do receive 3 meals a day which was Breakfast, Lunch and Dinner. Interview with an additional witness revealed that they would bring groceries to Resident and denied that facility was not feeding Resident in a timely manner. In regard to the allegation that staff financially abused resident, it was reported that Administrator is verbally abusive and is taking money from resident. Information obtained from interviews with staff, resident and witness did not corroborate the allegation that staff financially abused resident as resident was financially responsible for themselves. Interview with Administrator denied that R1 was financially abused by any staff at the facility, denied that any staff verbally abuses any resident. Interview with witness that R1 was not verbally abused and financially abused by any staff while living at the facility. LPA conducted a review of resident’s admission agreements and assessments did not corroborate the allegation that staff financially abused resident. Based on staff interviews, resident interviews, witnesses’ interviews, facility records, resident files, the allegations facility not feeding resident in a timely manner and staff financially abused resident is Unsubstantiated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Rance Leth and a copy of this report along with LIC811- Confidential Names list was provided.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 18-AS-20220422163744

Allegation investigated: Staff stole resident's bank statements. Resident does not have access to a phone. Facility overcharged resident for services.

Licensing Program Analyst, (LPA) Yolanda Delgado arrived unannounced to the facility to conclude an investigation pertaining to the allegations listed above. LPA met with Executive Director Rance Leth and explained the purpose of the visit. On April 22, 2022, Community Care Licensing received a complaint alleging staff stole resident’s bank statements, resident does not have access to a phone, and facility overcharged resident for services. LPA conducted interviews with Administrator, staff, residents, and additional witnesses. LPA also conducted a review of pertinent documentation. Regarding the allegation staff stole resident’s bank statements, it was reported that Administrator went into client’s room and stole bank statements. It was also reported that Administrator is taking money from Resident. Information obtained from the interview with Administrator denied that they retrieved any resident’s (Continued on Page 2) Unfounded (Continued from Page 1) bank statements and is taking any money from Resident. It was reported that Resident is responsible for their own finances. Information obtained from interview with Resident could not verify exact details of resident’s bank statements that were taken. Information obtained from an interview with an additional witness stated that staff did not steal Resident’s bank statements It was stated that Resident was in possession of all their banking information. It was further stated that there were no concerns regarding theft of Resident’s money or property. In regard to the allegation that Resident does not have access to a phone, it was reported that Resident is not allowed to use the phone. Information obtained from Administrator, indicated that Resident had access to a facility and mobile phone. It was advised that Resident was able to communicate with family when and as often as they desired. Interview with Administrator stated that two phones are available for any resident to use, and it is located at the front desk and the conference room for private calls. Information obtained from interview with Resident stated that a personal mobile phone can be used at any time. Information obtained from additional witnesses stated that Resident was able to speak with family and always had access to a phone. In regard to the allegation that facility overcharged resident for services, it was reported that Administrator charges Resident more than what was the admissions agreement indicates. Information obtained from interviews with Administrator stated that Resident’s Room Rate, Assisted Living Care Charge, laundry and cable services rate remained the same. It was advised that the Second Occupancy Rate increased to $50 on January 1, 2022. Information obtained from interview with Resident stated that charges were being billed and resident could not verify what the charges were. Information obtained from interview with an additional witness stated the facility was charging Resident as appropriate for the services. LPA conducted a review of resident’s admission agreement and assessments. All documents notifying of the increase were signed by resident. Based on staff interviews, resident interviews, witnesses’ interviews, facility records, resident files, the allegations staff stole resident’s bank statements, resident does not have access to a phone, and facility overcharged resident for services is Unfounded. (Continued on Page 3) (Continued from Page 2) meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Rance Leth and a copy of this report along with LIC811- Confidential Names list was provided.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 18-AS-20220422163744

Allegation investigated: Residents have become ill after eating the food served at the facility Resident has found hair inside the food and on plates

Licensing Program Analyst (LPA), Kathleen Banrasavong, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA met with Administrator, Rance Leth, and explained the purpose of the visit and the elements of the allegation. The investigation included observations, interviews with staff members and residents, and a review of records. On November 2, 2023, Community Care Licensing (CCL) received a complaint alleging that residents had become ill after eating food served at the facility and that a resident found hair inside their food and on the plates. It was alleged that three residents became ill after eating food at the facility. An interview with Administrator advised that kitchen staff follow proper protocols to ensure staff’s hair is covered during preparation. Unsubstantiated Administrator denied that the facility had an outbreak due to incorrect handling of food prepared at the facility. Administrator indicated that they were advised of the concern of hair in food, but was unsure of the origin. An interview with Dining Director indicated that the only complaint they received was for the lack of food options and denied receiving a complaint regarding residents getting sick from the food. LPA conducted interviews with additional staff members who indicated that they were unaware of any foodborne illnesses at the facility between August 2023 and November 2023. It was also advised there were no concerns of issues and concerns regarding food preparation. Information obtained from interview with Resident 1 (R1) stated they found food on their plate and alleged it was due to staff not wearing a hairnet. It was also reported that R1 became ill after eating the food and the facility was advised of the concern. Interviews conducted with two (2) of the three (3) residents named in the complaint revealed that they became ill after eating the food served at the facility. The residents could not remember the exact dates that they became ill. Additional interviews with residents indicated that they had not experienced any issues with hair in their food and did not become sick from eating food prepared at the facility. A review of documentation revealed that Community Care Licensing (CCL) did not receive any food borne outbreak reports during the period from August 2023 to November 2023. Also, there were no reports or documentation of residents being medically evaluated outside of the facility. During a visit conducted on 03/27/2024, kitchen staff were observed wearing the proper kitchen gear, including hairnets and uniforms. It was documented on a previous visit conducted on 11/03/2023, the LPA did observe staff to be without hairnets. LPAs did not observe any health and safety concerns. Based on information obtained, the allegations that residents became ill after eating food served at the facility and that a resident found hair inside the food and on plates are unsubstantiated. Although the allegations may have occurred or may be valid, there is not enough evidence to prove that the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was discussed with and provided to the Administrator, Rance Leth.the state’s words, verbatim · CDSS document, Feb 18, 2025 · control 18-AS-20231102114046

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct a Case Management visit pertaining to a self-report made to RO on 11/25/2024 for theft of money from a resident and 12/3/2024 for theft of a ring for a resident. LPA Delgado met with Administrator Rance Leth to explain the reason for the visit, Administrator stated that Law enforcement was called and police reports were filed. Administrator stated that a search was conducted for Resident #1 (R1)'s missing money and a partial of it was recovered and the ring was recovered by the Resident #2 (R2)'s relative. LPA interviewed Administrator and one (1) staff. During the visit, LPA toured the facility, observed sufficient staff, did not find no immediate health and safety concern. There are no deficiencies being cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted and a copy of this report was reviewed with and provided to Facility representative.the state’s words, verbatim · CDSS document, Dec 11, 2024

Type of visit: Required - 1 Year

On June 05, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the Administrator, Rance Leth. The facility file review was conducted in the Regional Office and additional forms were reviewed and requested on site. The facility is licensed for 220 ambulatory residents and has a waiver for 10 non-ambulatory residents. The facility currently operating at 200 residents of which 13 residents are on hospice, and about 30 residents in memory care. LPA Mixson toured the facility and inspected the facility inside and outside, and there were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a three floored facility located at 28333 Valley Blvd, Sun City, CA. 92586. Physical Plant: The facility phone number is(951) 679-8811. The LPA observed a sampling of the residents’ living units, and they were equipped with required furniture as per Title 22. LPA Mixson inspected a sampling of the facility restrooms, and the hot water temperature tested within regulations. The restrooms were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. The LPA observed required postings such as "If you See Something, Say Something" the "Personal Rights" and the Ombudsman postings. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently at the time of this visit. There was a pool and jacuzzi present which was fenced in meeting the height requirements. Medications: were locked and inaccessible to residents in care and located in the "Wellness Center." The overall facility is clean, the furniture is in good condition. The facility cooling system and other appliances were operable currently at the time of this visit, and there were safety lights throughout the building. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Kitchen utensils were in sufficient supply and stored properly, and sharps are locked. Care & Supervision: Facility has sufficient staff on site at the time of this visit. Records Review: The LPA reviewed resident and staff files, conducted staff and resident interviews. Previous Community Care Licensing forms were reviewed. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit. An exit interview was conducted, and a copy of this report was given to the Administrator, Rance Leth.the state’s words, verbatim · CDSS document, Jun 5, 2024

Allegation investigated: Facility is not maintained in good repair Staff does not ensure that facility is maintained at a comfortable temperature Staff does not ensure that facility dishes are properly cleaned and sanitized

Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility to deliver findings on a complaint investigation regarding the allegations listed above. LPA met with Christina Mulligan, Resident Care Coordinator, and explained the purpose of the visit. During the investigation interviews and record reviews were conducted. On 7/26/2023, Community Care Licensing received an allegation that the facility is not in good repair. It was alleged that the elevator located near the dining area keeps breaking down and is always out of service. Records review demonstrated that the facility has a contract with an elevator servicing company. LPA viewed documents which show service request dates and the date of service each time the elevator was not working. Documents viewed show that the elevator was repaired within 24 hours. Interviews with staff also demonstrated that the elevator was fixed in a timely manner and the facility made reasonable accommodations for residents to mitigate the impact. Interviews with residents demonstrated the impact was minimal and that residents had the option of using two other elevators as well as using a walkway ramp that is located outside next to the elevator. Based on observation, interview and record review this allegation is UNSUBSTANTIATED. Unsubstantiated On 7/26/2023, a complaint was received alleging staff does not ensure that the facility is maintained at a comfortable temperature for the residents. During the investigation interviews and record reviews were conducted. Interviews with residents revealed that it gets warm in the assisted living dining area but it is not unbearable because there are fans placed throughout the dining area. Residents interviewed also stated they are able to have their meals delivered to their rooms if it gets too warm. Interviews with staff revealed a new air conditioning system has been ordered for the assisted living dining area and in the meantime, fans are placed throughout the area. Staff also stated residents have the option of having meals delivered to their rooms. LPA toured the dining area and noticed three huge fans placed throughout the area. LPA observed the temperature to be at a comfortable level at the time. LPA viewed documents that revealed a purchase order for a new air conditioning system was placed for the dining area and expected to arrive in a few months. LPA also toured select residential units that were experiencing air conditioning issues. LPA observed portable air conditioners in place and units maintained a cool temperature. Based on observation, interview and record review this allegation is UNSUBSTANTIATED. On 7/26/2023, a complaint was received alleging staff does not ensure that facility dishes are properly cleaned and sanitized. LPA toured the kitchen area and inspected the dishwashing system. LPA observed a demonstration of dishes being cleaned and sanitized. LPA also observed clean dishes and clean silverware stored on shelves and on dining tables. Of the interviews conducted with residents, all residents indicated they were satisfied the facilities dishes, cups, silverware and that they all appeared to be clean. Of the interviews conducted with staff, all staff stated they have not observed or heard anyone complain about unclean or unsanitized dishes. Based on observation, interview and record review this allegation is UNSUBSTANTIATED; meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 29, 2023 · control 18-AS-20230726162249

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cheryl Goodrich arrived at 2:21pm to make an unannounced Case Management visit to the facility. LPA met Administrator, Rance Leth and explained the purpose of the visit. On 11/08/23 at 3:32PM, LPA observed live roaches and roach casings and eggs in 1/3 resident bedrooms and active bug bites on the residents in 3/3 resident bedrooms. LPA observed roaches running across the door, kitchen, floor, and bathroom floors. The residents in all 3 bedroom had either bite marks or rashes on their arms from the infestation. The Administrator stated he was aware of the infestation of roaches in the resident's room and treatment started 1 week ago for the resident and their neighbor but was unaware of issue in any other resident's room. The facility was cited for CCR 87303 (a) The facility shall be clean, safe, sanitary, and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. The facility is not in compliance with Title 22 Regulation, the deficiency can be found on the LIC 809-D page.the state’s words, verbatim · CDSS document, Nov 8, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Nov 9, 2023

87303 Maintenance and Operation. (a) The facility shall be clean, safe, sanitary, and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Based on observation and interview, the Administrator did not ensure that the facility is clean, safe, sanitary, and in good repair at all times. The facility did not ensure that maintenance include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.the state’s words, verbatim · CDSS document, Nov 8, 2023

Plan of correction: The Administrator indicated that Black Knight will be coming out for another visit either tomorrow or the following day. The Maintenance Director states they will approach the issue with a smile and try not to make it seem like they are mad when responding to the resident's complaints The Maintenance Director states they will approach the issue with a smile and try not to make it seem like they are mad when responding to the resident's complaints