Mercy Retirement & Care Center

Type of visit: Case Management - Incident

On 08/12/2026 at 11:20 AM, Licensing Program Analysts (LPA) David Doidge arrived unannounced to conduct a Case Management visit regarding an incident that was reported to CCLD on 08/10/2026 from an Unusual Incident Report (UIR). LPA met with Executive Director Kiel Stromaren and explained the purpose of the visit. The UIR states that on 08/07/2026, R1 eloped from the facility. LPA reviewed and obtained copies of R1’s Physician’s Report (602), facility’s assessment of R1, and Consent Form for Location Safety Device. LPA interviewed S1, S2 and S3. R1’s 602 indicates R1 is unable to leave unsupervised and unsafe wandering behavior. R1’s Wanderguard did set off the alarm, however staff did not react soon enough to prevent R1 from leaving the facility and grounds. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the appeal rights and this report provided.the state’s words, verbatim · CDSS document, Aug 12, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 84768.2(a)(4) · Plan of correction due date: Aug 26, 2026

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 services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on record review and interview, the licensee did not comply with section above by not ensuring care and supervision when R1 eloped which poses an immediate Health & Safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 12, 2026

Plan of correction: By POC date, the Executive Director agrees to conduct an in-service training with all staff regarding supervision and preventing elopement and send a copy of the training to CCLD.

Type of visit: Required - 1 Year

On 3/11/2026 at 10:45 AM, Licensing Program Analyst (LPA) Y. Brown conducted an unannounced annual 1-year required inspection. LPA met with Executive Director Kathleen McCarron and explained the purpose of the visit. The administrator currently holds a certificate (#7002969740) that expires on 2/3/2028. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, and back yard. All indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in a random sample of residents rooms were measured at 118.3, 115.3, and 107.4 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for residents. Smoke detectors and carbon monoxide combination were in operating condition during visit. Fire extinguisher was last purchased on 3/2/2026. First aid kit was observed to be complete. LPA reviewed five (5) staff and five (5) client records. LPA reviewed a sample of medication. Continued on LIC809C. Continued from LIC809. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 3/18/2026: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan No deficiencies cited during today's visit. Exit interview conducted with Kathleen and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 11, 2026

Type of visit: Case Management - Other

On 3/3/26, around 945am, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to amend the Complaint Investigation Report dated 01/05/2016 and to obtain the Administrator's signature on the amended report. LPA met with administrator Kathleen McCarron and explained to the administrator why the amendment. LPA amended the report, and after a short discussion about the amendment, the administrator signed the amended report. No citation during this visit. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 3, 2026

Allegation investigated: Residents sustain unexplained injury while in care

*****THIS IS AN AMENDED REPORT FROM VISIT 1/05/2026***** On 01/05/2026 at 9:45 AM, Licensing Program Analysts (LPAs) K. Nguyen and A. Christy arrived unannounced to conduct 10-day initial complaints and to deliver findings in regard to the allegation above. LPA met with Kathleen McCarron, Administrator, and explained the purpose of the visit. During the course of the investigation, LPAs conducted interviews and reviewed residents’ records, including but not limited to the resident’s staff roster, physician report, admission agreement, medication list, and after summary visit from dated Aug 2025 to Dec 2025. R1 was admitted to the facility on 2/1/25 till present. Report continues on LIC 9099c… Unsubstantiated ***report continues from LIC9099*** Review of R1’s medical records documents that R1 sustained approximately 8 falls once a month, resulting in multiple injuries and at least 8 hospital visits. Also documented in R1’s medical records were that R1 was a fall risk, however after reviewing R1 care plan shows fall injuries were counted for and the facility does have a fall intervention in place including but not limited to frequent check in every two hours, clutter free, assistive devices are available in good repair, the bed in low position, half bed rails and with soft matting around the bed. According to the SOC 341 obtained by the department, RP stated that the hospital staff found R1 on the hospital floor. R1 was sent out on 11/28/2025 by the facility via ambulance with an unwellness fall, and it was determined that any fall R1 experiences needs to be sent to the hospital due to R1's care plan. Before sending out, R1 was assessed, and the record shows that R1 did not have any injuries, but due to R1's conditions. The facility followed procedure and called 911 to transport R1 to the hospital, and informed the family member that R1 was sent out. LPAs interviewed S1, S2, S3, and S4; all confirmed that they did carry out the care prevention plan for R1. This agency has investigated the complaint alleging residents sustain unexplained injury while in care. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 5, 2026 · control 15-AS-20251229172122

Type of visit: Case Management - Other

On 01/05/2026 at 1:30PM, Licensing Program Analysts (LPAs) Andrew Christy and Kelly Nguyen conducted a Case Management regarding documentation during a complaint investigation. LPAs explained the nature of the case management to Kathleen McCarron, executive director. During the complaint investigation, LPAs conducted file review for a resident (R1) to ensure reporting requirements were being met. In the file, LPAs did not see incident reports for a fall in November and a wound being treated in December, though executive director claims they were submitted. LPAs requested these documents be sent to them by 01/07/2026, as well as the fax confirmation that they normally include with all sent incident reports. In addition, LPAs request the care notes done for the patient to be sent on 01/16/2025, covering the dates of 01/05/2026-01/15/2026. No deficiencies cited during visit. Exit interview conducted and a copy of this report was made available to the executive director.the state’s words, verbatim · CDSS document, Jan 5, 2026

Allegation investigated: Staff yelled at residents in care.

On 9/17/25 at 1:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver in regard to the allegations above. LPA met with Kathleen McCarron, Administrator and explained the purpose of the visit. During the course of the investigation LPA interviewed W1, facility residents (R1, R2, R3), R3’s Power of Attorney (W2 & W3), R3’s private caregiver (W4) and facility staff (S1, S2, S3). All facility residents, R1, R2 and R3, denied ever hearing staff yell at the residents and stated that they are treated with respect. All said that the staff at the facility are very helpful and kind. W2, W3 and W4 all stated that they also have never heard staff yell at the residents, including R3, describing the staff as thoughtful, kind and caring. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** Facility staff, S1, S2 and S3 also stated that they have never heard facility staff yell at the residents. S1 stating that if she ever did hear staff yell at the residents would be a disciple issue and that has not happened. This agency has investigated the complaint alleging staff yelled at residents in care. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 17, 2025 · control 15-AS-20250911164816

Allegation investigated: Staff did not provide adequate supervision resulting in a resident sustaining multiple falls

On 05/22/2025 at 2:00 PM, Licensing Program Analysts (LPAs) Greg Clark and Ardalan Gharachorloo arrived unannounced to deliver findings in regard to the allegation above. LPA met with Kathleen McCarron, Administrator and explained the purpose of the visit. During the course of the investigation the department interviewed W1, facility staff, facility residents, hospice staff and W2. The department also reviewed R1’s medical records. R1 was admitted to the facility on 12/28/23 because his health was deteriorating due to prostate cancer. R1 was on hospice at time of admission. Review of R1’s medical records document that R1 sustained approximately 7 falls within a 13-day span resulting in multiple injuries and at least two hospital visits. Also documented in R1’s medical records were that he was a fall risk, and that the facility should take measures to monitor his level of care to mitigate the risk of injuries from falls. ***CONTINUES ON 9099C*** Substantiated ***CONTINUES FROM 9099*** The department interviewed staff who stated they were aware that R1 was a fall risk but were never given any instructions from management to change the level of care they were providing to R1. Staff stated that they performed random checks on R1 every hour or two hours at most or more frequent whenever they got the chance but there was no formal monitoring plan in place. The only measures taken were that R1’s bed was lowered, and a fall mat was placed on the floor beside the bed. Multiple interviews with S1 revealed that fall preventative measures did not change and were the same beginning after R1’s first fall to the last fall incident. Based on the department’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted, a copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, May 22, 2025 · control 15-AS-20240410105909

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463 · Plan of correction due date: Jun 20, 2025

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition... (b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. Based on observation the licensee did not comply with the section cited above. R1 had multiple falls over a 2-week period and the facility never updated his appraisal.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Facility to review resident’s assessments for accuracy and update needs and services plans as needed. In addition, the facility will develop a procedure for how to they will disseminate changes from the reappraisals with direct care staff and submit it to CCL by POC date.

Allegation investigated: Questionable death

On 05/22/2025 at At, Licensing Program Analysts (LPAs) Greg Clark and Ardalan Gharachorloo arrived unannounced to deliver findings in regard to the allegations above. LPA met with Kathleen McCarron, Administrator and explained the purpose of the visit. During the course of the investigation the department interviewed the W1, facility staff, facility residents, hospice staff and W2. The department also reviewed R1’s medical records. Review of R1's medical records and death certificate revealed that R1’s cause of death was metastatic prostate cancer. R1 was diagnosed with prostate cancer in 2008. The department has investigated the complaint alleging questionable death. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted, a copy of this report provided. Unfoundedthe state’s words, verbatim · CDSS document, May 22, 2025 · control 15-AS-20240410105909

Allegation investigated: Staff did not administer medications as prescribed. Staff did not inform resident's responsible party of incidents in a timely manner.

On 05/22/2025 at 2:30 pm, Licensing Program Analysts (LPAs) Greg Clark and Ardalan Gharachorloo arrived unannounced to deliver findings in regard to the allegations above. LPA met with Kathleen McCarron, Administrator and explained the purpose of the visit. During the course of the investigation the department interviewed W1, facility staff, facility residents, hospice staff and W2. The department also reviewed R1’s medical records. R1 was admitted to the facility on 12/28/23 because his health was deteriorating due to prostate cancer. R1 was on hospice at time of admission. Allegation: staff did not administer medications as prescribed LPA reviewed R1’s medication administration records (MARs) for March and April 2024. MARs revealed that R1 was prescribed a total of 9 medications that were to be given as needed (PRN) for pain, anxiety, restlessness vomiting and constipation. ***CONTINUE ON 9099C*** Unsubstantiated ***CONTINUE FROM 9099*** R1 was also prescribed a daily aspirin. LPA observed that the PRN medications were all signed off as administered by the hospice nurses. From 4/01/24 until the time of R1’s passing on 4/10/24 he was given a total of 22 PRN medications for pain, restlessness, and anxiety. LPA observed that the MARs for the PRN medications were filled out according to regulation. Allegation: staff did not inform residents responsible party of incidents in a timely manner The department interviewed W2. W2 stated that she visited R1 regularly at the facility. W2 had no complaints regarding facility staff stating staff took care of R1 and provided him with sufficient supervision. W2 further stated that staff always instructed R1 to be careful when walking and would check on R1 all the time. LPA was unable to reach the W1 or W2 for further investigation as which incidents weren’t reported in a timely manner. This agency and the department have investigated the complaints alleging staff did not administer medications as prescribed, and staff did not inform residents responsible party of incidents in a timely manner. We have found that the allegations were unsubstantiated. 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, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, May 22, 2025 · control 15-AS-20240410105909

Type of visit: Required - 1 Year

On 4/16/25 at 11:00 a.m., Licensing Program Analyst (LPA) Greg Clark and Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Kathleen McCarron and explained the purpose of the visit. LPA toured the facility including but not limited to 5 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature in the art room was measured at 113.5 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. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 4/25/25. Emergency Disaster Plan was last signed on 9/12/24. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 4/15/25. LPAs reviewed 5 residents records and 5 staff records, and all were complete. LPAs also reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 16, 2025

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

On 4/16/25 at 2:30 p.m., Licensing Program Analyst (LPA) Greg Clark and Ardalan Gharachorloo arrived unannounced to conduct a case management visit on this date to provide technical assistance. LPAs received special incident report regarding numerous medication errors that occurred on 4/1/25 for 23 residents. The errors happened when the facility was switching pharmacies. LPAs spoke with Executive Director and reviewed the report with her. LPAs also toured the medication room and observed the current system of dispensing medications and storage. None of the residents experienced any side effects from the missing medications most of which where over the counter medications. Interview with the Executive Director revealed that the issue has been resolved and there have been no further medication errors occurred. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 16, 2025

Allegation investigated: Staff gave resident an improper notice/threat to evict

On 1/30/25 at 12:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Kathleen McCarron, Administrator and explained the purpose of the visit. During the course of the investigation it was determined that R1 does not live in the licensed facility. R1 lives in the Skilled Nursing Facility (SNF). LPA reviewed the roster for the SNF and found R1's name on it. This agency has investigated the complaint alleging staff gave resident an improper notice/threat to evict. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted, a copy of this report provided. Unfoundedthe state’s words, verbatim · CDSS document, Jan 30, 2025 · control 15-AS-20250124145204

Allegation investigated: Staff did not provide resident food in a timely manner. Staff are not providing resident with an adequate amount of food.

On 1/15/2025 at 12:50 PM, Licensing Program Analysts (LPAs) Greg Clark and Ardalan Gharachorloo arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPAs met with Executive Director, Kathleen McCarron and explained the purpose of the visit. During the course of the investigation LPAs interviewed W1 and S1. LPAs also visited and interviewed R1 in her room at the facility. W1 stated that he was worried that R1 was not receiving enough food in a timely manner. W1 further stated that he spoke to facility staff about the issue and now understands that since R1 is receiving the end of life care and she often refuses to open her mouth to eat or take her medications. W1 further stated that he is satisfied with the care that R1 is receiving at the facility. **CONTINUED ON 9099C** Unsubstantiated **CONTINUES FROM 9099** LPAs interviewed S1. S1 stated that R1 is currently on hospice and receiving the end of life care. There was a period of time that R1 did not eat for five days. S1 further reported that R1 often refuses to open her mouth to accept food, drink and medications. S1 also reported that staff make every effort to encourage R1 eat and drink but are often unsuccessful. S1 is confident that R1 is receiving an adequate amount of food in a timely manner as tolerated. This agency has investigated the complaint alleging staff did not provide resident food in a timely manner and staff are not providing resident with an adequate amount of food. We have found that the complaint was unsubstantiated. 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, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 15, 2025 · control 15-AS-20250109083518

Allegation investigated: Staff confiscating resident’s personal belongings. Staff did not allow resident to finish mealtime.

On 10/03/2024 at 10:30 AM, Licensing Program Analyst (LPA) Greg Clark and Ardalan Gharachorloo arrived unannounced to conduct an initial 10-day complaint investigation in regard to the allegations above. LPA met with Adminsitrator Josephine Davis and explained the purpose of the visit. LPAs interviewed S1 who stated R1 lives in the Mercy Retirement & Care Center’s Skilled Nursing Facility(SNF). He does not live in the building licensed by CCL. LPAs reviewed resident rosters of both facilities and found R1 on the roster for the SNF.LPAs visited SNF and spoke with R1 who confirmed his residency and date of birth. This agency has investigated this complaint. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted, a copy of this report provided. Unfoundedthe state’s words, verbatim · CDSS document, Oct 3, 2024 · control 15-AS-20240926094138

Type of visit: Case Management - Other

On 10/03/24 at 11:15 a.m., Licensing Program Analyst (LPA) Greg Clark and Ardalan Gharachorloo arrived unannounced to deliver amended report for the LIC9099 dated 9/12/24. LPA met with Elvira Suciu, Resident Care Director (RCH) and explained the purpose of the visit. Amended report delivered to RCH. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 3, 2024

Allegation investigated: Staff are not allowing a resident in care access to their personal property

On 9/12/24 at 2:15 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Elvira Suciu, Resident Care Diector and explained the purpose of the visit. During the course of the investigation LPA interviewed the RP and S1. LPA also visited R1 in her room at the facility. During the visit LPA observed R1 in her room. R1 was wearing headphones, and the laptop was on. S1 asked R1 if she was tired and R1 responded yes. S1 took off the headphones and closed the laptop. R1 immediately turned her head and closed her eyes. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** Currently the facility staff provide R1 access to the laptop as tolerated by the resident. This agency has investigated the complaint alleging staff are not allowing a resident in care access to their personal property. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 12, 2024 · control 15-AS-20240903082932

Allegation investigated: Staff do not ensure that resident's dietary needs are met Staff are not following resident's feeding plan

On 8/15/24 at 11:30 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation in regard to the allegations above. LPA met with Elvira Suciu, Resident Care Diector and explained the purpose of the visit. During the course of the investigation LPA interviewed the Reporting Party (RP) and S1. LPA also reviewed R1’d file and observed R1 in her room. R1 was admitted to the facility on 9/02/23 on hospice. R1 has a diagnosis of Parkinsonism and unspecified dementia. R1’s diet is prescribed as “thickened to a honey consistency.” LPA observed thickened liquids in R1’s room and in her refrigerator. Currently R1 has difficulty swallowing, pocking food and is on aspiration precaution. S1 stated that R1’s condition has been declining slowly since her admission. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** Allegation: Staff do not ensure that resident's dietary needs are met. Based on file review, observation and interviews this allegation is unsubstantiated. Allegation: Staff are not following resident's feeding plan. Based on file review, observation and interviews this allegation is unsubstantiated. This agency has investigated the complaint alleging staff do not ensure that resident's dietary needs are met and staff are not following resident's feeding plan. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 15, 2024 · control 15-AS-20240808082122

Allegation investigated: Staff unlawfully evicted a resident Staff did not meet a resident's oxygen needs Staff mishandled a resident's personal belonging

On 6/19/24 at 2:20 p.m., Licensing Program Analysts (LPAs) Greg Clark and A. Gharachorloo arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Josephine Davis, Administrator and explained the purpose of the visit. LPAs interviewed S1 who stated R1 lives in the Mercy Retirement & Care Center’s Skilled Nursing Facility(SNF). He does not live in the building licensed by CCL. LPAs reviewed resident rosters of both facilities and found R1 on the roster for the SNF. This agency has investigated this complaint. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted, a copy of this report provided. Unfoundedthe state’s words, verbatim · CDSS document, Jun 19, 2024 · control 15-AS-20240617122846

Type of visit: Case Management - Health Checks

On 4/12/24 at 11:00 AM, Licensing Program Analyst (LPA) Greg Clark conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Elvia Suciu, Resident Care Director and explained the purpose of the visit. LPA toured facility including but not limited to the apartments, bathrooms, common area, kitchen, and outdoor area. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Refrigerator temperature was observed at xx degrees F. Resident's medications were kept locked in med carts. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observed. First-aid kit was complete. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 12, 2024

Type of visit: Required - 1 Year

On 3/19/24 at 1:00 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Josephine Davis, Administrator and explained the purpose of the visit. The facility’s fire clearance was approved for 160. LPA toured the facility including but not limited to 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 70 degrees F. The hot water temperature in a residents’ bathroom was measured at 116.2 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. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 3/07/24. Emergency Disaster Plan was last posted on 10/02/23. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 2/27/24. LPA reviewed 5 residents records and 5 staff records, and all were complete. LPA also reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 19, 2024

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Health Checks

On 1/04/24 at 12:30 PM, Licensing Program Analyst (LPA) Greg Clark conducted a Health & Safety inspection as a result of notice received from Attorney General Bonta that he had approved a conditional change in the control and governance of this facility from Elder Care Alliance to Transforming Age. LPA met with Administrator, Josephine Davis and explained the purpose of the visit. Due to the facility being in an active COVID out break status LPA was unable to tour the facility or speak to residents. LPA interviewed S1 during the visit. S1 reported that on 12/15/23 a public meeting was held at the facility to discuss the change of control and governance of the facility. In attendance were: residents and family members, facility staff, the CEO's of both Elder Care Alliance and Transforming Age and the Assistant Attorney General of the State of California. The meeting lasted approximately 1.5 hours. S1 further reported that there have been no changes at the facility. All staff and residents remain stable and there is no plans, at this point, to change any of the residents' contract to reflect the change of control and governance. The old contracts will remain in place. No issues identified at this time. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 4, 2024