Merrill Gardens at Gilroy

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Simi Rai arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with Business Office Director, Cristine Rivo and stated the purpose of today's visit. The purpose of the visit to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on June 13, 2024. LPA Rai reviewed facility files pertaining to the Corrective Action Training Plan created in response to the Non-Compliance Conference. During today's visit, LPA toured the facility with staff to include Garden House/ Memory Care Unit, Plaza/Assisted Living unit, and common areas. There were 10 staff members total on schedule during the AM shift in Plaza, and Garden House. LPA reviewed the facility's roster on Guardian and observed the 10 out of 10 staff members are fingerprint cleared and associated to the facility. LPA Rai toured 5 random rooms in Garden House and in Plaza and did not observe resident having access to sharp objects, chemicals, disinfectants, and hygiene products to residents in care with Dementia and did not observe any issues related to residents having access to sharp objects, chemicals, disinfectants, and hygiene products to residents who are able to do so per their physician's reports/records. Continuation on LIC 809-C, page 1 of 2. Page 2 of 2. LPA Rai reviewed all training topics stated on the non-compliance plan. LPA Rai reviewed the following training records: On 05/26/2026, General Safety Survey was completed wherein 46 staff were in attendance. On 04/23/2026, Fire & Alarm Test was completed wherein 42 staff were in attendance. On 02/26/2026, Fire Procedure Orientation was completed wherein 7 staff were in attendance. LPA Rai reviewed at random 5 resident files. 5 Out of 5 resident files were complete, to include a signed personal rights form, updated physician’s report, and a signed updated appraisal/needs and services plan. LPA Rai reviewed at random 5 staff files. 5 Out of 5 staff files were complete, to include all staff are fingerprint cleared and associated to the facility. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Business Office Director, Cristine Rivo and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 29, 2026

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management – legal/non-compliance visit. LPA met with General Manager (GM), Billy Mitchell. The purpose of the visit is to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) office at a non-compliance meeting held on June 13, 2024. During visit, LPA toured the facility with staff to include Garden House ( memory care unit), Plaza, common areas. There are 2 Med Techs and 4 caregivers in Assist Living for AM shift and PM shift. There are 4 caregivres and 1 Med Tech for Memory Care unit for AM shift and PM shift. LPA reviewed the facility's roster and observed the 11 staff members are associated to the facility. In Garden House, LPA randomly entered into rooms #101A, #100, #102A, #101B, #103, #104 and #106A with GM. All the cabinets observed secured. No observation of accessible sharp objects, chemicals, disinfectants, and hygiene products to residents in care with dementia. In Plaza, LPA randomly entered into rooms #227, #226, #225, #223, #222, $216, #214 with GM. No issues were noted. Residents who store their own chemicals, disinfectants and hygiene products are able to store these items per their physician's report/records. Continue on LIC809-C. Page 1 of 2. LPA observed all training topics stated on the non-compliance plan was completed with signature log - fall policy; resident rights, toxic chemicals, and fire & alarms; and change of condition and mandated reporting. 5 random resident files were reviewed and observed complete. 5 resident files contained a signed personal rights form, updated physician’s report, and a signed updated appraisal/needs and services plan. 5 random staff files were reviewed. 5 staff are fingerprint cleared and associated to the facility. LPA advised GM regarding the importance of adhering to the facility's corrective action plan that was developed on June 13, 2024, to ensure the facility's stays within compliance of Title 22 regulation. GM was reminded of the discussion on June 13, 2024 of the facility being under monitoring inspection visits to ensure compliance with the compliance plan and Title 22 Regulations for 2 years. No deficiencies were cited today. This report was reviewed with General Manager Billy Mitchell and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 24, 2026

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with General Manager (GM), Billy Mitchell. The purpose of the visit to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on June 13, 2024. During visit, LPA toured the facility with staff to include garden house (aka memory care), plaza, common areas. There were 7 staff members total on schedule during the AM shift in the Garden House. LPA reviewed the facility's roster on Guardian and observed the 14 staff members are fingerprint cleared and associated to the facility. In Garden House, LPA randomly entered into rooms 127, 126B, 126A, 125B, 120, 115A and 101A with the Garden House Director. All the cabinets observed secured. No observation of accessible sharp objects, chemicals, disinfectants, and hygiene products to residents in care with dementia. In Plaza, LPA randomly entered into rooms 304, 302, 203, 202, 209, 211 with the GM. No issues were noted. Residents who store their own chemicals, disinfectants and hygiene products are able to store these items per their physician's report/records. Page 1 Out of 2. LPA observed all training topics stated on the non-compliance plan was completed on September 17, 2025 - fall policy; September 13, 2025 - resident rights, toxic chemicals, and fire & alarms; and September 15, 2025 - change of condition and mandated reporting. 5 random resident files were reviewed and observed complete. 5 resident files contained a signed personal rights form, updated physician’s report, and a signed updated appraisal/needs and services plan. 5 random staff files were reviewed. 5 staff are fingerprint cleared and associated to the facility. LPA advised GM regarding the importance of adhering to the facility's corrective action plan that was developed on June 13, 2024, to ensure the facility's stays within compliance of Title 22 regulation. GM was reminded of the discussion on June 13, 2024 of the facility being under frequent monitoring inspection visits to ensure compliance with the compliance plan and Title 22 Regulations for 2 years. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager Billy Mitchell and a copy of the report was provided. Page 2 Out of 2. END OF REPORT.the state’s words, verbatim · CDSS document, Nov 6, 2025

Allegation investigated: The licensee did not comply with the resident’s admission agreement resulting in the resident being charged excess fees

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the finding for the above allegation. LPA met with Executive Director, Billy Mitchell. On 07/10/2025, the Department received the complaint alleging that the licensee did not comply with resident (R1)’s admission agreement resulting in R1 being charged excess fees. On 07/17/2025, the initial complaint investigation was conducted. Documents were obtained to include resident roster, resident (R1)'s admission agreement, ledger, progress notes, and correspondence. Page 1 of 2. Substantiated Based on the reporting party (RP), it was reported that R1 moved into the facility in October 2024 and in late November 2024, R1 required hospitalization following almost 3 months at a rehab center (November 2024– February 2025). While R1 was in rehab, R1 was charged for assisted living care services in December 2024, after being told by the facility staff that R1 would only be charged monthly rent for the apartment. Based on the facility’s admission agreement with R1, it’s stated under the apartment hold policy that “When you have been away from your Apartment for 14 consecutive days, credit for Assisted Living Services will be given beginning on day 15 until you return”. On 07/17/2025, the General Manager was interviewed who stated that the Business Office Director (BOD) who was handling the R1’s credit no longer works for the community and did not leave any communication regarding R1’s billing. It was stated that the BOD already had prior approval back in December 2024 to credit the amount back to the resident’s account but the GM was unsure why the BOD did not complete the refund. The GM admitted that the credit was not completed in December 2024. On 07/17/2025, the GM and VP of Operations processed the credit back to R1’s account. Proof of the ledger showing the credit was provided to the Department. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided. Page 2 of 2.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 26-AS-20250710154104

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Oct 2, 2025

(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not comply with the section cited above wherein the licensee did not comply with the terms and conditions set forth in resident (R1)’s admission agreement by not ensuring R1 was credited assisted living care services costs per the admission agreement timeframe which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: On 07/17/2025, the GM and VP of Operations credited back R1’s assisted living care services costs and submitted the ledger to LPA Kabariti showing the care cost was credited back. Deficiency cleared during visit.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with General Manager (GM) Billy Mitchell and Health Services Director (HSD), Jocelyn Bailon Saloche. During visit, LPA toured the facility with the HSD to include the common areas, kitchen, resident bedrooms, bathrooms, and exterior. Facility temperature maintained between 71 to 74 degrees F. All emergency exits were clear of obstruction. Activities calendar and menu posted in a visible area. It was observed that the only elevator in the facility that goes to Plaza (2nd and 3rd floor) had "out of order" signs posted. GM stated the elevators broke down yesterday on 09/24/2025 around 3:00pm. GM stated that they immediately called the vendor and had a technician come to the facility the same day around 4:30pm - 5:00pm. They were informed that the elevator is still functional however, the doors will not automatically close on its own but the elevator can be operated manually. GM states as of today, if any of the residents want to use the elevator, they need to call a staff to assist them in the elevator. GM states all the staff are trained on how to operate the elevator manually. In addition, they residents (who are able) and staff are using the stairwells. LPA observed the stairwells are equipped with evac chairs. GM states that they are offering in-room dining for residents who rather stay in their rooms and activities on the 2nd and 3rd floor of Plaza. GM is actively working with the vendor to fix the elevator. Page 1 of 2. Kitchen is supplied with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Items inside the refrigerator observed covered and labeled. Refrigerator temperature maintained at 39 degrees F. Freezer temperature was maintained at 8 degrees F. Staff stated they had the freezer opened which may have affected the temperature. The kitchen staff showed a log of the freezer temperatures which they monitor every morning, and logged below 0 degrees F. Toxins, chemicals and disinfectants are secured and stored separately from the food supply. A total of 9 resident bedrooms were observed. 9 resident bedrooms are equipped with beds, linens, night stands, dressers, and adequate lighting. Oxygen in use signs posted on the doors of residents who are using oxygen per physician's orders. Between 11:20AM - 12:30PM, the hot water temperature was measured in rooms #125B, 120, 118B, 203, 209, and 306 which measured between 132.6 - 136.4 degrees F. The maintenance personnel stated they had their water boiler serviced recently. During visit, facility had a plumber who was actively working on reducing the hot water temperature. At 4:26PM, the hot water was measured and observed maintained at 115.5 degrees F. 7 resident records were reviewed and observed complete and up-to-date. 5 out of 7 residents were on medication management. The 5 residents centrally stored medications and records were reviewed and all medications were accounted for. 5 staff files were reviewed and observed complete and up-to-date to include a background clearance. The staff are provided annual training on topics to include but not limited to dementia, Alzheimer's, prohibited and restricted health conditions, hospice, pressure sores, medications, caregivers, and blood borne pathogens. The facility is equipped with smoke and carbon monoxide detectors. Fire extinguishers were last serviced on 4/26/2025. LPA observed the facility first aid kit and it was observed to be complete. The facility fire/earthquake/elopement drill log was reviewed and drills are being conducted quarterly. The last drill was conducted in August and September 2025. Facility has an updated emergency disaster plan and infection control plan. No deficiencies were cited today per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 25, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with General Manager (GM), Billy Mitchell and Health Services Director (HSD) Jocelyne Bailon Saloche. The purpose of the visit to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on June 13, 2024. During visit, LPA toured the facility with staff to include garden house (aka memory care), plaza, common areas. There were 14 staff members total on schedule during the AM shift in Prom/Plaza, and Garden House. LPA reviewed the facility's roster on Guardian and observed the 14 staff members are fingerprint cleared and associated to the facility. In Garden House, LPA randomly entered into rooms 111A, 116B, 120, 125B, 126A, and 126B with the Garden House Director. All the cabinets observed secured. No observation of accessible sharp objects, chemicals, disinfectants, and hygiene products to residents in care with dementia. In Plaza, LPA randomly entered into rooms 203, 209, 211, 301, 304, and 309 with the HSD. No issues were noted. Residents who store their own chemicals, disinfectants and hygiene products are able to store these items per their physician's report/records. Page 1 of 2. LPA observed all training topics stated on the non-compliance plan was completed on 02/19/2025 - fall policy; 06/19/2025 - resident rights, toxic chemicals, and fire & alarms; and 07/17/2025 - change of condition and mandated reporting. The training document contains the topic, date, name and signatures of the participants. LPA advised the GM to ensure all staff (including new staff members) are provided annual training on these specific topics per the non-compliance plan. 5 random resident files were reviewed and observed complete. 5 resident files contained a signed personal rights form, updated physician’s report, and a signed updated appraisal/needs and services plan. 5 random staff files were reviewed. 5 staff are fingerprint cleared and associated to the facility. LPA advised GM regarding the importance of adhering to the facility's corrective action plan that was developed on June 13, 2024, to ensure the facility's stays within compliance of Title 22 regulation. GM was reminded of the discussion on June 13, 2024 of the facility being under frequent monitoring inspection visits to ensure compliance with the compliance plan and Title 22 Regulations for 2 years. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and Health Services Director, Jocelyne Bailon Saloche and a copy of the report was provided. Page 2 of 2.the state’s words, verbatim · CDSS document, Aug 19, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. LPA met with General Manager (GM) Billy Mitchell. The purpose of the visit was to follow-up on two incidents that was reported to the Department on 07/14/2025 and 07/17/2025. On 07/14/2025, the Department was notified of alleged abuse between resident (R1) and R1’s private caregiver. It was stated that on 07/14/2025 around 1:00am, R1 pulled his/her pull cord and when staff responded R1 reported that he/she felt dizzy because R1’s private caregiver hit him/her in the head. Staff immediately contacted 911 and assessed the resident. There were no visible injuries such as bruising, redness, scratches, or marks on R1’s skin. The police arrived and R1 did not know why the police was there. The facility reported the incident to R1’s responsible party and felt R1 wasn’t in the right state of mind. Based on interview and record review, R1 has mild cognitive impairment and history of confusion upon waking up. R1’s family continued to keep services from the same private caregiver. Staff stated the resident has shown no indications of abuse. R1's physician's report, service plan and progress notes were obtained. On 07/17/2025, the Department was notified of a medication error that occurred during the morning shift of 07/17/2025. It was reported that the MedTech in training (S1) administered resident (R2)’s medication to resident (R3). See LIC809-C for additional information. S1 was shadowing another MedTech (S2) on the floor. During the medication pass, S1 and S2 did not reconfirm the resident's medication prior to administering it. When S1 and S2 went to administer R2’s medication, the staff noticed they only had R3’s medication cup and then realized that R3 was given R2’s medication. R3 already left the community with family once the medication error was found. R3’s family and physician was immediately informed. The facility staff advised R3's authorized representative to seek medication attention, however it was stated that R3 was doing well. It was stated R3's family will monitor R3 during their outing and take action when needed. The facility plans to remove both MedTechs from the floor. Both MedTechs will be required to complete the medication training courses again prior to working on the floor. The Licensee will also provide training for the MedTech trainers regarding medication pass oversight between the trainer and trainee. The review of the facility’s compliance history showed another medication error of a similar incident occurred on 02/25/2025. The incident was reported to the Department on the same day. On 02/27/2025, LPA Kabariti followed up with the incident via phone call and it was stated that R1 was administered R2’s medication on accident by a MedTech in training (S3). S3 was shadowing MedTech (S4). S3 grabbed the wrong medication cup and did not reconfirm the medication prior to administering it to R1. R1 was taken to the hospital for monitoring and returned to the facility on the same day. Based on interview and record review, there were not adverse reactions from the medication error. After the incident, the facility removed both MedTechs from the floor and were required to complete re-training on medications. Based on record review, S4 completed the re-training on medications after the incident. Staff stated that S3 did not want to continue to pursue the MedTech position. Based on review of S1 – S4’s staff training records, S1 – S4 completed multiple training courses regarding medications. A deficiency was cited per California Code of Regulations, Title 22 regarding the medication errors. See LIC809-D. This report was reviewed with General Manager, Billy Mitchell and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 17, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jul 18, 2025

a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. … This requirement is not met as evidenced by: Based on interview and record review, the licensee did not ensure that staff were competent to assist residents with medication administration in 2 counts wherein 2 resident’s were administered another resident’s medication on 02/25/25 and 07/17/25 which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: Licensee immediately removed the MedTechs who were part of the medication errors and the staff were required to re-complete medication training. Licensee will also provide in-service training to MedTech trainers regarding medication pass oversight. Licensee will submit the in-service training document to LPA Kabariti via email by POC due date of 07/18/2025.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management visit. LPA met with General Manager (GM), Billy Mitchell. The purpose of the visit was to hand deliver an immediate exclusion letter for an individual (S1) who the Department determined engaged in conduct inimical. S1 was not currently working in the facility. It was stated that S1 only worked in the facility a couple times during the summer of 2024. The immediate exclusion letter was handed to the GM. The GM was informed to remove S1 from any contact with residents and not allow S1 to be physically present in the facility. GM stated understanding. The Business Office Director (BOD) was advised to separate S1 from the facility roster. BOD stated understanding. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 25, 2025

Allegation investigated: Staff did not give resident medication as prescribed

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to open the initial complaint investigation. LPA met with Health Services Director (HSD) Jocelyne Bailon Saloche. On 06/03/2025, the Department received a complaint alleging that the facility staff are not giving resident (R1) medication as prescribed. On 06/06/2025, the initial complaint investigation was conducted. The following documents were obtained to include resident (R1)'s physicians report, appraisal/needs and services plan, eMAR summary for April and May 2025, medical records, current medication list, and email correspondences. Page 1 of 2. Unfounded On 04/04/2025, the facility was provided R1’s hospital discharge summary which listed multiple changes to R1’s medication regimen. On 05/31/2025, a staff from the facility called R1’s responsible party asking if he/she was okay with the change to R1’s medication (M1) as stated on the updated LIC602. Upon reaching out to R1’s primary care physician (PCP), it was discovered that no changes were made since 04/03/2025. During the investigation, it was found that a staff (S2) had called R1’s responsible party to inform him/her about a change in R1’s medication (M1) per a new physician’s report that was received on 05/30/2025. Based on interview with S2, S2 admitted to misspeaking about the medication change during the call with R1’s responsible party. It was stated that S2 was confused about R1’s PM (M1) medication order because S2 only works AM shifts and was not familiar with R1’s PM medication regimen. Upon further reviewing R1’s medications, S2 then realized that R1 did not have a change in medication order. S2 states that R1 continued to receive his/her medication as normal and no changes to his/her medication regimen was actually made. Based on interview with staff (S1), S1 corroborated S2’s statement. The review of records shows that R1’s medication (M1) order did not change and R1 continued to receive his/her medication as prescribed by the physician. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded, meaning the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Health Services Director, Jocelyne Bailon Saloche and a copy of the report was provided. Page 2 of 2.the state’s words, verbatim · CDSS document, Jun 6, 2025 · control 26-AS-20250603161256

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with General Manager (GM), Billy Mitchell and Health Services Director (HSD) Jocelyne Bailon Saloche. The purpose of the visit to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on June 13, 2024. During visit, LPA toured the facility with staff to include garden house (aka memory care), plaza, common areas, and the courtyard. There were 9 staff members total on schedule during the PM shift in Prom, Plaza, and Garden House. 9 out of 9 staff members are fingerprint cleared and associated to the facility. In Garden House, LPA randomly entered into rooms 101A, 102A, 103, 110, and 115 with the Garden House Director and HSD. All the cabinets observed secured. No observation of accessible sharp objects, chemicals, disinfectants, and hygiene products to residents in care. In Plaza, LPA randomly entered into rooms 207, 210, 211, 212, and 203 with the HSD and GM. No issues were noted. Residents who store their own chemicals, disinfectants, and medications are able to store these items per their physician's report/records. Page 1 of 2. LPA observed all training topics stated on the non-compliance plan was completed on July 18, 2024. The training topics includes resident rights, mandated reporting, changes of condition, toxic substances and sharp objects. Staff were also provided in-service training on personal rights in December 2024 and toxic chemical storage in February 2025. The training document contains the topic, date, name and signatures of the participants. LPA advised the GM to ensure all staff (including new staff members) are provided annual training on these specific topics per the non-compliance plan. 5 random resident files were reviewed. 5 resident files reviewed contained a signed personal rights form, updated physician’s report, and a signed updated appraisal/needs and services plan. 5 random staff files were reviewed. 5 staff are fingerprint cleared and associated to the facility. LPA advised GM regarding the importance of adhering to the facility's corrective action plan that was developed on June 13, 2024, to ensure the facility's stays within compliance of Title 22 regulation. GM was reminded of the discussion on June 13, 2024 of the facility being under frequent monitoring inspection visits to ensure compliance with the compliance plan and Title 22 Regulations for 2 years. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided. Page 2 of 2.the state’s words, verbatim · CDSS document, May 28, 2025

Allegation investigated: Staff are overcharging residents in care Staff are falsifying documents Staff do not keep resident's information confidential

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the finding of the above allegations. LPA met with General Manager, Billy Mitchell. On 05/24/2024, the Department received the complaint. On 05/29/2024, the initial complaint investigation was conducted. The following documents were obtained to include the resident roster, 7 resident records to include a physician’s report, needs and services plan, progress notes, identification and emergency contact information. It was alleged that the facility is overcharging residents in care for services they are not providing. It was alleged that resident (R3) is being charged for showers but R3 shower him/herself. Page 1 of 4. Unsubstantiated The review of R3’s records indicates that R3 is paying for shower services as R3 requires moderate assistance with showers. Based on interview with R3, it was stated that upon admission in the facility (April 2024) R3 was refusing showers due to a fall incident that occurred in another care facility. R3 states he/she was not comfortable with showers yet and refused the shower service. R3 denied the facility missing a shower week, besides one week when the facility did not have hot water which R3 received a shower the week after. R3 states that he/she receives shower weekly and did not have any complaints about the services he/she is receiving. It was alleged that resident (R4) is being charged for showers and laundry but R4’s family does the laundry and R4 showers him/herself. The review of R4’s records indicates that R4 is not paying for shower services and requires minimal assistance with showers. Records show that R4 is paying for weekly laundry services. Based on interview with R4, it was stated that R4 shower him/herself. R4 stated that the staff does his/her laundry weekly and did not have any complaints about the services he/she is receiving. It was alleged that resident (R5) is receiving shower services but is being charged for dressing services, when R5 can dress him/herself. The review of R5’s records indicates that R5 is paying for shower services as R5 requires moderate assistance with showers. R5 is independent in dressing and is not paying for this service. Page 2 of 4. Based on interview with R5, it was stated that R5 received weekly shower services since the day R5 has moved in. R5 denied the staff missing a shower week. R5 states he/she is able to dress him/herself daily but sometimes may need assistance from the staff. R5 did not have any complaints about the services and care he/she is receiving and states the facility is meeting his/her daily needs. It was alleged that the facility staff are falsifying documents because the staff are making the residents sign documents that has been written by staff to be completely untrue. It was also alleged that staff are falsifying documents as they are told by S1 to not to document everything because it leaves a paper trail. 4 residents were interviewed. Based on resident interview, 4 out of 4 resident’s denied staff falsifying their documents. 4 staff members were interviewed. Based on staff interview, it was stated by staff (S3) that a former staff was told not to document everything because it leaves a paper trail and S1 does not want a paper trail. Another staff stated that S1 instructed S2 to falsify other documents (pendant log) during a licensing visit. Based on interview with S1 and S2, both staff denied falsifying documents. S1 stated that a former staff was claiming that he/she was told not to document anything, when the documentation actually needed to be completed by another staff member. S1 also denied instructing S2 to falsify the pendant logs. Based on interview with the former staff, it was stated that he/she was told by another staff (name unknown) that S1 had directed the other staff to falsify documents. Based on interview with S2, it was stated that S2 was helping to print the pendant logs. S2 denied S1 instructing him/her to falsify the pendant log by changing the times and believes they are not able to modify the times in the pendant system. Page 3 of 4. It was alleged that staff (S1) did not keep resident’s information confidential by disclosing a resident’s death to other residents. 3 staff members (S2 – S4) were interviewed. Based on staff interview, 3 out of 3 staff stated that the residents found out about another resident’s death by staff (S1). It was stated that S1 disclosed the information to resident (R1) and (R2). Based on interview with S1, S1 denied disclosing a resident’s death to other residents. 2 residents (R1 – R2) were interviewed. Based on resident interview, R1 and R2 denied staff disclosing a resident’s death to them. R1 and R2 states they found out about the resident’s death through other residents at the facility, and not by the staff. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegations are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided. Page 4 of 4.the state’s words, verbatim · CDSS document, Apr 9, 2025 · control 26-AS-20240524084602

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. This visit is a follow-up to a case management visit conducted at the facility on 05/29/2024. LPA met with General Manager, Billy Mitchell. On 05/23/2024, the Department was informed of resident (R1)’s death that was observed by staff during morning check-ins with the residents. The Department was investigating the allegation of neglect/lack of supervision resulting in R1 committing suicide while in care. During the investigation, it was found that at approximately 0945 hours, staff checked in with R1 as R1 did not check in with the front desk by 0830 hours based on the facility’s policy. When staff entered R1’s bedroom, staff found R1 deceased inside his/her bedroom by apparent suicide. A note was found stating that R1 acted alone without any assistance. The facility staff immediately called 911. Staff members and resident were interviewed. Based on interviews, R1 never made any suicidal statements and/or had suicidal ideations. R1 was independent and did not require any kind of assistance. Based on record review of R1’s file, documents did not indicate or notate any signs of depression or suicidal behaviors. Facility staff did not provide and could not state how R1 obtained items used to aid in his/her death. Page 1 of 2. The review of the police report records indicated that there were no signs of trauma or foul play. The Department has investigated the allegation to be unsubstantiated, meaning, although the incident may have happened and/or did occur, there is not a preponderance of evidence to prove a Title 22 violation. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Billy Mitchell and a copy of the report was provided. Page 2 of 2.the state’s words, verbatim · CDSS document, Apr 9, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Christine (Dolores) Kabariti arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with General Manager, Billy Mitchell. The purpose of the visit to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on June 13, 2024. During visit, LPA toured the facility with staff to include garden house (aka memory care), plaza, common areas, and courtyard areas. During the tour, LPA observed 11 staff members who are fingerprint cleared and associated to the facility. In Garden House, LPA randomly entered into rooms 125A, 124, 122A, 120, and 113 with the Garden House Director. All sharp objects, chemicals, disinfectants, and garden supplies observed secured in garden house. LPA observed 1 out of the 5 rooms had hygiene products accessible, however, based on the resident's physician's report the resident is not at risk if allowed direct access to these items. LPA observed the resident's room door was closed. In Plaza, LPA randomly entered into rooms 210 and 202 with the Health Services Director. LPA observed 1 out of 2 resident rooms (R1) contained chemicals/disinfectants to include laundry detergent and dish soap accessible in the cabinet underneath the kitchen sink. Based on review of this resident's (R1) file, the resident is diagnosed with dementia and should not have access to chemicals/disinfectant items per the signed physician's communication sheet. HSD removed the items immediately and informed the resident. Page 1 of 2. Based on the non-compliance plan, training was scheduled to be completed by a certain date for reporting requirements; change of condition and observations of decline in condition or ability; personal rights of a resident; reappraisals; and care of persons with dementia as it pertains to toxic substance and sharp objects. LPA observed all training topics stated on the non-compliance plan was completed on July 18, 2024. Staff were also provided in-service training on personal rights in December 2024. The training document contains the topic, date, name and signatures of the participants. LPA advised the GM to ensure all staff are provided annual training on these specific topics per the non-compliance plan. 5 random resident files were reviewed. The files reviewed contained a signed personal rights form, physician’s report, and a signed up-to-date appraisal/needs and services plan. 5 random staff files were reviewed. 5 staff are associated to the facility and fingerprint cleared. LPA Kabariti advised to ensure all new staff review and receive instruction regarding resident rights upon hire and the training must be documented in the staff’s file. LPA advised GM regarding the importance of adhering to the facility's corrective action plan that was developed on June 13, 2024, to ensure the facility's stays within compliance of Title 22 regulation. GM was reminded of the discussion on June 13, 2024 of the facility being under frequent monitoring inspection visits to ensure compliance with the compliance plan and Title 22 Regulations for 2 years. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with General Manager, Billy Mitchell and Health Services Director, Jocelyne Bailon and a copy of the report and appeal rights was provided. Page 2 of 2.the state’s words, verbatim · CDSS document, Feb 20, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Feb 21, 2025

(a) ... the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, ... and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.This requirement is not met as evidenced by: Based on record review, interview and observation the licensee did not ensure to keep toxic items inaccessible to resident (R1) who is diagnosed with dementia and should not have access to cleaning solutions and toxins per the physician, which posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 20, 2025

Plan of correction: Licensee immediately removed the toxic items from resident (R1)'s room. Licensee will submit an in-service training for all staff regarding appropirate chemical safety for residents with dementia. Licensee will submit the in-service training document to LPA Kabariti via email by POC due date.

Allegation investigated: Facility staff took resident belongings Facility staff did not follow residents care plan

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding for the above allegations. LPA met with General Manager, Billy Mitchell. On 02/26/2024, the Department received the complaint. On 03/06/2024, the initial complaint investigation was conducted. The following documents were obtained for this investigation to include 2 residents’ identification and emergency information, physician’s report, service plan, progress notes, safeguard of personal properties and valuables, facility’s policy and procedures on medication management, evaluation and service planning, and email correspondences. It was alleged that the facility staff took resident (R1)’s 5 bottles of medications, two pill organizers, and multivitamins inside his/her room while R1 and R1’s spouse was not present in their room. Page 1 of 3. Substantiated It was also alleged that staff did not follow R1’s care plan as R1’s care plan states he/she is not on medication management when staff removed the medications from R1’s bedroom. 1 staff member was interviewed regarding this investigation. This staff member was present and involved in removing R1’s medication from R1’s bedroom. Based on staff interview, R1 was not under medication management during the time of move-in and the General Manager at the time approved R1’s spouse to help administer R1’s medications. One day [specific date unknown], S1 was directed by the General Manager to remove R1’s medications from his/her room. The reason the medications needed to be removed was after the facility nurse determined R1 needed assistance with medication management after completing a 30-day medication evaluation after admission. However, the nurse did not provide and finalize the updated evaluation prior to removing the medications from R1’s bedroom. S1 stated that prior to removing R1’s medications from his/her room, the staff did not notify R1 or R1’s spouse and/or family member that R1’s medications would be removed. S1 admitted this to be a mistake as they should have notified R1 and R1’s responsible parties prior to removing the medications. R1’s spouse became upset with staff, in which staff returned R1’s medications. Based on record review, R1’s service plan upon admission dated 12/30/2023 indicated that R1 was independent and did not require assistance with medication administration. It’s indicated that R1 could self-manage his/her medications. R1’s service plan was updated in July 2024. Based on R1’s physician’s report from January 2024, it stated that R1 had mild cognitive impairment and was able to administer own prescription medication, able to administer own PRN medication and able to store own medications. The review of records does not show any incidents concerning R1’s medication compliance and safety by storing his/her own medication. There were also no records from R1’s physician regarding the change of R1’s capacity to store his/her own medications or other diagnosis which would deem unsafe if R1 would store his/her medications. Page 2 of 3. The Department has investigated the above allegations. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegations are substantiated. A deficiency is being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with General Manager, Billy Mitchell and a copy of the report and appeal rights were provided. Page 3 of 3.the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 26-AS-20240226134837

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Dec 20, 2024

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did ensure to comply with the section cited above by not informing R1 and R1’s authorized representatives of the need to remove R1’s medications from his/her room prior to removing the medications, despite R1’s care plan not requiring medication management which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 19, 2024

Plan of correction: Licensee will provide an in-service training with staff regarding the appropriate steps for when a resident is determined to need medication management, to include proper communication with the resident and resident's authorized representatives. Licensee will submit the in-service training document to LPA Dolores via email by POC due date of 12/20/2024.

Allegation investigated: Staff did not follow resident’s care plan

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding regarding the above allegation. LPA met with General Manager, Billy Mitchell. On 03/28/2024, the Department received the complaint. On 04/05/2024, the initial complaint investigation was opened. The following documents were obtained to include resident (R1)’s physician’s report, service plans, progress notes, incident reports, resident roster, and staff schedule. On 03/01/2024, resident (R1) sustained an unwitnessed fall and reported that it had been about 2 hours before anyone came to check in on R1. It was alleged that the staff did not follow R1’s care plan of checking in on R1 every hour. Upon R1’s visit to the hospital on 03/04/2024, it was found that R1 sustained an injury to the head, leg swelling, and back pain. Page 1 of 2. Unfounded On 04/05/2024, 5 staff members were interviewed. Based on staff interview, it was stated that staff check in on R1 at least 2 times per day for medications, however caregivers check in on R1 about 2 or 3 times more per shift. It was stated that there were no incidents reported for R1 on 03/01/2024. The number of times staff check in on R1, was depending on the staff. S2 stated to check in on R1 about 3 – 5 times per his/her shift. S3 states to check in on R1 at least 4 times per his/her shift. S4 states to check in on R1 about 4-5 times per his/her shift. Based on record review, on 03/01/2024, there were no progress notes written by staff on this day. On 03/02/2024, it was noted that R1 requested for pain reliver medication due to pain. From 03/02/2024 – 03/04/2024, R1 was on alert charting due to a change of condition and was being monitored for his/her pain. On 03/03/2024, staff mentioned concern that R1’s pain could be a cause of a fall. On 03/04/2024, R1 was taken to the hospital by his/her family member where R1 was seen for a swollen ankle. The review of records show that R1 is a high potential for falls but does not require assistance with ambulation, mobility, escorting, and transferring. On R1’s service plan, it states that R1’s family member has been evaluated by the community to be at risk for injury which may cause permanent disability or be life threatening. Interventions were put in place for R1’s safety, however, based on record review there was no indication on R1’s service plan that staff were required to check in on R1 every hour. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded, meaning the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided. Page 2 of 2.the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 26-AS-20240328152505

Allegation investigated: Staff did not ensure residents had adequate night supervision Staff did not answer resident’s call buttons in a timely manner

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegations. LPA met with General Manager, Billy Mitchell. On 05/23/2024, the Department received a complaint. On 05/29/2024, the initial complaint investigation was conducted. The following documents were obtained for this investigation to include the staff schedule, LIC500, for May 2024, pendant logs, and 2 staff files. It was alleged that the facility does not have adequate night supervision because on Sunday and Monday there is only one caregiver and one medtech scheduled to work the NOC shift. Page 1 of 3. Substantiated It was also alleged that it’s difficult for staff to respond to residents call buttons in a timely manner due to the low number of staff who work the night shift. It was stated that instead of the response times being between 5-10 minutes, it has increased to 20-30 minutes On 05/29/2024, 3 residents were interviewed. Based on resident interview, 2 out of 3 residents states that the facility does not have enough night supervision. It was stated that there is only 2-night shift staff for the whole building. 4 staff members were interviewed throughout this investigation. Based on staff interview, 2 staff states there is not enough night supervision staff. 2 staff states there is only two staff who work the NOC shift. It was stated that there were some days where only one staff would work the NOC shift. S3 stated that there was a time before S3 was hired when there was only 1 NOC shift staff working in Prom and Plaza. Based on record review, the NOC staffing schedule in May 2024, it shows only 1 caregiver scheduled in the Prom/Plaza (Assisted Living) section of the facility on Sunday and Mondays. Based on staff interview, the standard NOC staffing schedule should be 2 staff in the prom and plaza area. Based on resident interview, 2 out of 3 residents states a negative experience with the facility’s pendant system. R1 states a time where he/she was sitting on the floor for about 45 minutes before a staff responded to his/her pendant call. R2 states that no one comes for about 45 minutes. R2 states in the morning, it takes about half an hour to an hour for staff to respond. Based on review of R1’s pendant call logs, it shows that in May 2024 there were 88 calls that had a response time of 10 minutes and more. 33 out of 88 calls had over a 30-minute response time. 26 out of 88 calls had over a 15-minute response time between the hours of 10:00PM – 6:00AM. Page 2 of 3. Based on review of R2’s pendant calls logs, it shows that in May 2024 there were 55 calls that had a response time of 10 minutes or more. 16 out of 55 calls had over a 30-minute response time. R2 did not press the call button between the hours of 10PM – 6AM. Based on interview with the General Manager, the expectations is for staff to respond to the residents call button within 15 minutes. The Department has investigated the above allegations. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegations are substantiated. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with General Manager, Billy Mitchell and a copy of the report and appeal rights were provided. Page 3 of 3. On 06/12/2024, 3 residents were interviewed. Based on interview, 3 out of 3 residents stated the bedsheets are self-provided and staff assist with washing their bedsheets. 3 out of 3 residents denied being left in bed without bed sheets. Based on interview with R1, R1 denied being left in bed without bed sheets. R1 states that staff has changed his/her sheets in the middle of the night because he/she wet the bed, but staff did place another set of sheets on his/her bed. R1 states that some of the staff are not able to change his/her sheets in the middle of the night but R1 stated that staff always provided him/her with bed sheets. On 06/12/2024, LPA Dolores observed R1’s bed had bedsheets. A witness (W1) was interviewed. W1 stated that R1’s bed sheets were self-provided. W1 states a time where he/she observed R1’s bed was made but upon checking the bed, W1 observed R1’s bed sheets were stained with urine and blood. W1 thinks that the night staff might have left R1 in bed with the urine and blood-stained sheets because the staff was not able to lift R1. W1 denied observing R1 without bed sheets. The Department has investigated the above allegation. Based on interview and observation the above allegation is unsubstantiated. An unsubstantiated finding indicated that although the allegation is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 26-AS-20240523113501

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 20, 2024

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, … (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 evidenced by: Based on interview and record review, the licensee did not ensure there was enough staff scheduled in prom and plaza during the NOC shift in May 2024 and did not ensure staff responded to the resident’s call buttons within 15 minutes, which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 19, 2024

Plan of correction: Licensee is currently scheduling 2 caregivers for Prom and Plaza during the NOC shift, which is the facility's standard ratio for NOC. Licensee will submit the staffing schedule for the NOC shift which shows their standard staffing ratio. Licensee will also provide an in-service training to staff regarding timely pendant call response times. Licensee will submit the in-service training to LPA Dolores via email by POC due date on 12/20/2024.

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Christine Dolores and Marcella Tarin arrived unannounced to conduct a case management visit to deliver an immediate exclusion letter for staff (S1). LPAs met with General Manager (GM), Billy Mitchell. On 12/06/2024, the Department conducted an initial visit to investigate a reported incident involving physical abuse to resident (R1) by staff (S1). The incident occurred on the night of 12/02/2024 and the facility was informed on 12/03/2024. On 12/03/2024, S1 was escorted out of the building and on 12/04/2024, S1's employment was terminated from the facility. LPAs provided a letter "Order to Licensee/Facility of Immediate Exclusion From Facility" That the department determine that S1 engaged in conduct inimical as a staff in the facility. GM was informed to remove S1 from any contact with residents and S1 may not be physically present in any facility. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. The Department issued a citation under 87468.1(a)(3) Personal Rights. S1's aggressive action towards R1 violated R1's personal rights when S1 quickly dragged R1 across the room to the bathroom, covered R1's mouth, and pushed R1 to the ground causing R1 to sustain bruises on his/her shoulder area and toes. This report was reviewed with General Manager (GM) Billy Mitchell and a copy of the report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 10, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Dec 11, 2024

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature,... This requirement is not met as evidenced by: Based on interview, record review and observation S1's aggressive actions towards R1, the night of 12/02/2024 violated R1's personal rights, which poses/posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 10, 2024

Plan of correction: Licensee terminated S1 on 12/4/2024. Licensee conducted an in-service training after the incident on 12/4/24 and 12/5/24 to include topics of understanding the importance of “see something say something”; mandated reporters; the steps to take to ensure residents safety and well-being; and understanding resident rights. Deficiency was cleared during visit.

Allegation investigated: Staff did not safeguard resident's personal belongings. Staff did not ensure that resident's hygiene needs were met while in care. Staff did not ensure that resident had clean linens while in care. Staff did not follow safe sanitation practices.

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegation. LPA met with Health Services Director, Jocelyne Bailon. On 07/24/2023, the Department received the complaint. On 08/03/2023, the initial complaint investigation was conducted. Documented were obtained for this investigation to include the resident roster, staff schedule, resident (R1)’s progress notes, service plan, shower schedule, safeguard of personal property and valuables (LIC821), theft and loss policy, and facility training on infection control. It was alleged that the facility staff did not safeguard resident (R1)’s dentures as it was observed missing by R1’s family member. It was alleged that R1’s missing dentures was not replaced after it was brought to the attention of the facility staff. Page 1 of 3. Unsubstantiated The review of R1’s service plan states that R1 has full dentures but refuses to wear the dentures. 4 staff members were interviewed. Based on staff interview, 4 out of 4 staff did not remember R1 using dentures. It was stated that R1 moved from Assisted Living to Memory Care and staff did not remember R1 moved into memory care with dentures. Based on record review of R1’s safeguard of personal property and valuable form, there were no items to include the dentures that was entrusted to the facility. The word “waived” is written across the form and the form was signed and dated by R1’s responsible party on 03/17/2021. It was alleged that the facility staff did not ensure that R1’s hygiene needs were met while in care as it was observed that R1 was filthy after not being bathed for a week. It was alleged that R1’s hygiene needs were not met because the facility was short staffed. The date of this encounter is unknown. Based on record review, R1’s showers were scheduled twice a week and required staff hands on assistance. 4 staff members were interviewed. Based on staff interview, 4 out of 4 staff denied R1’s hygiene needs being neglected by the staff. Staff states that R1’s family did not bring up any concerns that R1 wasn’t showered for a week. Staff states the facility was short staffed around July 2023 but denied the shortage of staff reflecting on the shower schedule. Staff states the residents were still being provided their showers on their scheduled days. The review of the facility’s staffing schedule shows that there were at least 3 staff scheduled in memory care, in the AM and PM. It was alleged that staff did not ensure R1 had clean linens while in care as there was a day where R1’s responsible party and R1’s social worker needed to change R1’s bedsheets because they were soiled. Page 2 of 3. The date of this encounter is unknown. 4 staff members were interviewed. Based on staff interview, 4 out of 4 staff were not able to recall a time where R1 had soiled linens. It was stated that if staff were to observe that a resident’s sheets are soiled, the staff would immediately change the sheets and put new ones. It was alleged that staff did not follow safe sanitation practices as a staff who wore disposable gloves for cleaning was touching other surfaces and items with the same glove on. It was stated that when R1’s responsible party placed R1’s soiled items outside R1’s bedroom door for laundry service, the staff picked up the soiled linens with possibly the same disposable gloves. It was stated that the staff did not serve R1 any food. The reporting party did not indicate that the staff provided any care to the resident or other residents with the same gloves used during cleaning. 4 staff members were interviewed. Based on staff interview, it was stated that they spoke with the alleged staff who did not follow safe sanitation practices, and the staff denied the allegation. It was stated that facility staff are provided training on infection control. Staff state that they can use gloves when cleaning but they are trained to change out their gloves before they provide any care to the residents. It was stated that staff are trained to change their gloves after every resident when assisting them with ADL (activities of daily living) care. Based on record review, infection control training was completed on 05/25/2023. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Health Services Director, Jocelyne Bailon and a copy of the report was provided. Page 3 of 3.the state’s words, verbatim · CDSS document, Dec 6, 2024 · control 26-AS-20230724122911

Allegation investigated: Facility did not seek medical care for multiple residents who were exhibiting symptoms of scabies Facility did not communicate with residents physicians for a change of condition Facility did not quarantine residents who were exhibiting symptoms of scabies Facility is not discarding PPE gowns after assisting residents with a contagious disease

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the findings of the above allegations. LPA met with Health Services Director, Jocelyne Bailon. On 12/08/2023, the Department received the complaint. On 12/15/2023, the initial complaint investigation was conducted. The following documents were obtained to include resident roster, 5 residents physician's report, appraisal/needs and services plan, progress notes, and third-party communication notes. It was alleged that 5 residents (R1 – R5) were showing symptoms of scabies and the facility did not seek medical care and communicate with the resident’s physicians for multiple residents who were exhibiting symptoms. Page 1 of 3. Unfounded On 12/15/2023, 6 staff members were interviewed. Based on staff interview, there were a couple residents who were diagnosed with scabies on separate occasions (10/26/2023 and 11/06/2023), but as of 12/15/2023 the residents no longer had scabies. It was stated that some residents did not have a confirmed diagnosis of scabies and were experiencing symptoms of itchiness. These residents’ physicians were notified and prescribed a PRN medication. The review of records show that R1 was noted to have itchiness and redness on 10/26/2023. Based on staff interview, R1 was diagnosed with scabies. R1’s hospice nurse was notified and R1 was prescribed and applied a PRN medication. Staff noted R2 was experiencing symptoms of itchiness. R2’s doctor and authorized representative was notified, and R2 was prescribed a PRN medication. R2 was also being seen by a home health agency for another condition. Staff stated that R3’s itching was caused by dry skin. R3’s doctor was informed and prescribed a PRN medication. Staff denied the observation of R3’s skin being red and bumpy. R4 was noted to be under hospice care. Staff stated that R4 was not exhibiting any symptoms. The review of R4’s records did not include notes of a diagnosis of scabies or symptoms of itchiness. Staff stated that R5 was being seen by a home health agency and was not experiencing any symptoms of scabies. The review of R5’s records did not include notes of a diagnosis of scabies or symptoms of itchiness. It was alleged that staff are not discarding PPE gowns after assisting residents who are under isolation or quarantine because they were not told to discard it. It was also alleged that residents who were experiencing symptoms of scabies were not placed under quarantine. Page 2 of 3. On 12/15/2023, 6 staff members were interviewed. Based on staff interview, 6 out of 6 staff members stated they discarded the PPE gowns after every use. Based on review of the facility’s infection control plan, it’s stated that items and equipment that are single-use shall be disposed of in an appropriate waste container with a tight-fitting cover. Based on staff interview, the gowns being used are disposable and they are disposed in the trash bin upon exiting the resident rooms, which is located next to the isolation room. Staff stated that resident’s who were suspected to have scabies and were experiencing symptoms of scabies were placed under isolation until they were informed of a diagnosis from the resident’s physicians. Those who were experiencing itchy skin due to a condition not related to scabies (example dry skin), were not placed under quarantine. Based on review of the facility’s infection control plan, it’s stated there shall be separation and care of residents whose illness requires separation, including quarantine or isolation, from others. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unfounded, meaning the allegations are false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Health Services Director, Jocelyne Bailon and a copy of the report was provided. Page 3 of 3.the state’s words, verbatim · CDSS document, Dec 6, 2024 · control 26-AS-20231208112008

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a follow-up case management – incident visit that was initiated on 05/29/2024. LPA met with Health Services Director, Jocelyne Bailon. On 05/25/2024, resident (R1) passed away at the facility and the cause of death was an accident. R1 had ligature strangulation in the setting of ethanol use. Based on R1’s evaluation report dated 11/30/2023, R1 had a history of substance use which may cause some interpersonal and/or health problems but does not significantly impair overall independent functioning. However, staff still had concerns about R1’s alcohol consumption and overall safety after drinking alcohol. Based on R1’s progress notes, R1 had multiple fall incidents from 2021 – 2024 resulting in injuries. Staff interviewed were aware that R1 was a fall risk, had multiple fall incidents and liked to drink alcohol. The review of R1’s assessment shows R1 was last re-assessed on 11/30/2023, even though R1 continued to be a fall risk and had multiple falls resulting in injuries after 11/30/2023. There was no reassessment completed after 11/30/2024. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty of $1000 is being assessed today for a repeat violation within 12 months. See LIC421IM. Failure to correct the deficiency may result in additional civil penalties. An additional Civil Penalty for a violation resulting in serious bodily injury of a resident is pending review. This report was reviewed with Health Services Director, Jocelyne Bailon and a copy of the report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 6, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a)(3) · Plan of correction due date: Dec 7, 2024

(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. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) … This requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not comply with the section cited above wherein the facility did not reassess R1 after 11/30/2023, even though R1 continued to be a fall risk and had multiple falls resulting in injuries after 11/30/2023 which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 6, 2024

Plan of correction: Licensee states they will reassess residents upon a change of condition immediately. Licensee will submit a statement of understanding of the section cited and the plan going forward, to LPA Dolores via email by POC due date (12/07/24).

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit. LPA met with Health Services Director, Jocelyne Bailon. The purpose of the visit was to follow-up on a physical abuse incident that occurred at the facility the night of 12/02/2024. On 12/03/2024, the Department was informed of an incident that occurred between staff (S1) and resident (R1). On 12/03/2024, the community was made aware that R1 was treated in an aggressive manner by S1 the night of 12/02/2024. The incident was captured on the facility's fall detection video system. After the community was made of the incident, S1 was escorted out of the building on 12/03/2024. S1’s employment was terminated on 12/04/2024. The facility also conducted an internal investigation with all the staff involved and who have witnessed the fall detection video footage. On 12/04/2024 and 12/05/2024, the facility conducted an in-service training with all staff (AM/PM/NOC) to include topics of understanding the importance of “see something say something”; mandated reporters; the steps to take to ensure residents safety and well-being; and understanding resident rights. HSD states the training also included proper intervention and techniques for redirection, de-escalation, and dementia. Documents were obtained to include the in-service training sheet/materials and 4 staff member’s job application. A copy of the fall detection video was provided to LPA Dolores via a USB stick. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Health Services Director, Jocelyne Bailon and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 6, 2024

Allegation investigated: Facility does not have sufficient staffing in memory care to meet the needs of residents

Licensing Program Analyst (LPA) Christine Dolores arrived to the facility unannounced to deliver the finding of the above allegation. LPA met with General Manager Billy Mitchell. On 08/16/2023, the Department received the complaint. On 08/22/2023, the initial complaint investigation was conducted. The following documents were obtained to include staff schedule, caregiver job description, resident roster, and 4 resident’s files. It’s alleged that the facility does not have sufficient staffing in memory care (aka Garden House) to meet the needs of the residents, as it’s alleged that there is an average of 2 caregivers daily for all of the residents in memory care. It was alleged that the caregivers are also required to do housekeeping chores to include dishwashing, which does not allow the staff time to provide care to the residents. PAGE 1 OF 3. Unsubstantiated On 08/22/2023, 1 witness was interviewed. Based on witness (W1) interview, it was stated that the facility is short staffed mostly everyday. It was stated that the morning and afternoon shift has 2 caregivers and 1 medtech. W1 states that on 08/22/2023, there was only 2 staff. W1 states that he/she is constantly looking for staff to help R1. W1 states if he/she is really complaining the staff come within 10-15 minutes. W1 stated that on 08/22/2023, staff came after 45 minutes and apologized for not coming sooner as the staff needed to take a lunch. W1 states it doesn’t happen often. On 08/22/2023, 8 staff members were interviewed. Based on staff interview, 7 out of 8 staff stated the facility’s memory care has sufficient staff to meet the needs of the residents. It was stated that there are 4 staff (3 caregivers and 1 medtech) in the morning shift, 3 staff (2 caregivers and 1 medtech) in the evening shift, and 2 staff for the overnight shift. It was stated that the staff used to wash dishes around December 2022 time, however, since August 2023 the kitchen staff does all of the dishes. It was stated that the staff are assigned to groups, and they help each other out as a team. It was stated that the medtech also assist with care giving duties, when needed. 1 out of 8 staff stated they need more staff in memory care. On 08/22/2023, LPA Dolores entered the memory care unit around 11:50am and observed 2 staff were working in memory care, 1 caregiver and 1 medtech/caregiver. Based on interview with staff, the third caregiver was on break and the fourth caregiver was somewhere in the building but could not be located at that moment. LPA Dolores observed 3 housekeeping staff. After a few minutes, LPA observed the third caregiver walking down the hallway. LPA interviewed the fourth caregiver who states to be late to work. LPA Dolores observed lunch started at 12:10PM and observed 2 staff assisting the residents with dining. Based on record review, there were 30 residents residing in memory care. PAGE 2 OF 3. Based on record review of the facility’s staffing schedule, in July 2023 the AM and PM shift had 3 caregivers and 1 Medtech scheduled and 2 staff for NOC shift. There was only 1 day of the month (Saturday 07/22/2023) where there was only 2 caregivers and 1 Medtech scheduled in the PM. In August 2023 the AM shift had 3 caregivers and 1 Medtech, PM shift had 2 caregivers and 1 Medtech, and NOC shift had 2 staff scheduled. On 08/22/2023, the schedule shows 3 caregivers and 1 Medtech in the AM and 2 caregivers and 1 Medtech in the PM. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicated that although the allegation is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided. PAGE 3 OF 3.the state’s words, verbatim · CDSS document, Oct 29, 2024 · control 26-AS-20230816163108

Allegation investigated: Facility's call button is not operable and reachable to the resident

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the complaint investigation findings. LPA met with General Manager, Billy Mitchell. On 10/10/2023, the Department received the complaint. On 10/18/2023, the initial complaint investigation was conducted. The following documents were obtained for this investigation to include resident (R1)’s physician’s report, hospice paperwork, POLST, service plan, progress notes, POA documents, personal rights form, alert button logs, and death report. It was alleged that the facility’s call button is not operable and reachable to the resident as resident (R1)’s family member pressed the call button, and no one answered. It was also alleged that the call button is too far of reach from R1’s bed. PAGE 1 OF 2. Substantiated On 10/18/2023, LPA Dolores entered into R1’s bedroom. R1’s bed was removed as R1 passed away early morning of 10/18/2023. LPA observed an alert button on the wall that was placed above the night stand. Based on interview with staff (S1) and (S2), R1’s bed was located to the right of the night stand. LPA observed that the alert button may not be of arms reach if a person is laying down in bed. The alert button did not contain a pull cord. Based on interview with S2, S2 stated that R1 was not able to reach the button. LPA Dolores pressed the alert button above the night stand at 2:34PM and there was no response from staff at 2:45PM (11 minutes after the alert button was pressed). At 2:39PM, LPA entered room #2 located right next to R1’s room. At 2:39PM, LPA pressed the alert button next to the bed. 2:41PM, S1 pushed the alert button in the bathroom. 2:42PM, LPA Dolores pressed the alert button next to the bed a second time. At 2:45PM, there was no response from staff. Based on record review, R1’s alerts were not responded to on 10/07/2023, 10/08/2023, 10/10/2023, 10/12/2023, 10/15/2023, 10/17/2023, and 10/18/2023 (7 different occasions). The Department has investigated the above allegation. Based on record review and observation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with General Manager, Billy Mitchell and a copy of the report and appeal rights was provided. PAGE 2 OF 2. Based on record review, R1 was under hospice care. On 10/10/2023, R1’s family member called 911 and the paramedics and police arrived to the facility. Based on interview with S2, R1’s family member called 911 because R1 was not feeling well. The paramedics arrived to the facility and assessed R1 and R1 verbalized that he/she wanted to stay and did not want to go to the hospital. S2 states the facility was instructed by R1’s hospice team to call 911 if the resident sustains an injury like a fall. The review of R1’s records indicates that R1 was a DNR and on comfort focused treatment. The Department has investigated the above allegation. Based on interview and record review the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided. PAGE 2 OF 2. Based on record review, the facility obtained both POA documents from two of R1’s family members. The first POA document is dated in 2020 and the second POA document is dated in 2023. Based on interview, S1 and S2 states they received two POA documents from both family members. The second POA document dated 2023 was when R1 already had dementia. S2 states they were using the initial POA documents while pending further clarification from the facility’s corporate office on if the second POA document was valid as it was dated when R1 already had dementia. It was alleged that the facility staff does not allow R1 to have a voice in memory care because R1 sits with the same person during meals every day and R1 does not even like the person he/she sits with. It was alleged that the staff does not listen to R1 because R1 has Dementia. Based on staff interview, R1 did not have a preference of who he/she wanted to eat with. R1 would agree with whoever family member is in the room. R1 did not verbalize that he/she wanted to sit with certain residents or staff during mealtime. The Department has investigated the above allegations. Based on interview and record review, the above allegations are unfounded meaning the allegations are false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager Billy Mitchell and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 29, 2024 · control 26-AS-20231010113934

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 30, 2024

(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 evidenced by: Based on interview, record review and observation the licensee did not comply with the section cited wherein R1's alert button was not responded to on 7 different occasions and based on LPA Dolores observation on 10/18/23 which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: Licensee will conduct a staff training regarding responding to call buttons in Garden House (aka Memory Care). Licensee will submit the training document to LPA Dolores via email by POC due date.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with General Manager, Billy Mitchell. The purpose of the visit to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on June 13, 2024. During visit, LPA toured the facility with GM to include garden house, assisted living, common areas, and courtyard areas. During the tour, LPA observed 9 staff members who are fingerprint cleared and associated to the facility. All sharp objects, chemicals, disinfectants, and garden supplies observed secured. Based on the non-compliance plan, training was scheduled to be completed by a certain date for reporting requirements; change of condition and observations of decline in condition or ability; personal rights of a resident; reappraisals; and care of persons with dementia as it pertains to toxic substance and sharp objects. LPA observed all training topics stated on the non-compliance plan was completed by the expected dates. The training document contains the topic, date, name and signatures of the participants. GM states a plan to complete the training bi-annually. Page 1 of 2. 5 resident files were reviewed. The files reviewed contained a signed personal rights form, physician’s report, and a signed up-to-date appraisal/needs and services plan. 5 staff files were reviewed. 5 staff are associated to the facility and fingerprint cleared. 5 staff are provided training on personal rights as of 10/29/2024. LPA Dolores advised to ensure all new staff review and receive instruction regarding resident rights upon hire and the training must be documented in the staff’s file. LPA Dolores advised GM regarding the importance of adhering to the facility's corrective action plan that was developed on June 13, 2024, to ensure the facility's stays within compliance of Title 22 regulation. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 29, 2024

Allegation investigated: Facility staff are not reappraising resident after falls Resident sustained injuries due to multiple falls while in care

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegations. LPA met with General Manager, Billy Mitchell and Resident Care Director, Jocelyne Bailon Solache. On 12/15/2022, the Department received a complaint regarding the above allegations. On 12/22/2022, the initial complaint investigation was conducted. The following documents were obtained to include resident (R1)’s service plans, physician’s report, preplacement appraisal, functional capabilities assessment, progress notes, admission agreement and emergency contact information. 3 other resident records were obtained. PAGE 1 OF 3. Substantiated It was alleged that the facility staff are not reappraising resident (R1) after falls resulting in resident sustaining injuries due to multiple falls. R1’s service plans from year 2021 - 2022 were reviewed. The review of records shows that on 04/07/2022, R1 was re-evaluated, and the fall potential section was updated from a low potential to a moderate potential for falls. The service plan included an action plan to check on R1 during med passes, meals and activities, provide night lights, arrange items within reach, slip mats in bathtub/shower, showers are draining properly, change heights of items to accommodate resident, remove trip hazards, check carpet/floor for intact surfaces, rearrange furniture if appropriate, emergency devices working and within reach, and room clutter. On 04/29/2022, R1 was re-evaluated, and the fall potential section was updated from moderate potential to high potential for falls. There were no action plans indicated on the service plan. The re-evaluation was based on a fall that was noted in R1’s record on 04/30/2022. Between 04/30/2022 – 09/08/2022, R1 was noted to have 8 falls (05/29, 06/24, 07/03, 07/05, 07/06, 08/08, 08/11, and 08/28). On 09/09/2022, R1 was re-evaluated, and the service plan was updated to still indicate a high potential for falls. The service plan included an action plan to include removing trip hazards and room clutter. Between 09/10/2022 – 11/22/2022, R1 was noted to have 14 falls (09/23, 09/24, 09/25, 10/01, 10/05, 10/07 (R1 noted to have 2 falls this day), 10/10, 10/31, 11/03, 11/05, 11/07, 11/08, 11/21). On 11/23/2022, R1 was re-evaluated, and the service plan was updated to still indicate a high potential for falls. The service plan included an action plan to use walker, arrange items to be within reach, and remove trip hazards. PAGE 2 OF 3. . The review of records show that R1 sustained injuries after falls on 08/28/2022 and 11/05/2022. On 08/28, R1 was observed to sustain a bump on his/her left forehead with redness. 911 was called and resident was not sent out after further assessment and discussion with family. On 11/05, R1 was sent to the hospital for a fall and unresponsiveness. Resident returned to the facility with the left forehead and cheeks swollen. On 11/06, resident was seen with a contusion on the right facial area post fall. On 12/12/2022, a witness observed resident was walking in the hallway without a walker with a big bump on the left forehead area. R1 denied a fall. R1 was transferred to the hospital and returned the same day with new medication. Based on record review, the facility did not re-evaluate and update R1’s service plan after falls on 05/29, 06/24, 07/03, 07/05, 07/06, 08/08, 08/11, 09/23, 09/24, 09/25, 10/01, 10/05, 10/07, 10/10, 10/31, 11/03, 11/05, 11/07, 11/08, and 12/12. The Department has investigated the above allegations. Based on record review and observation the preponderance of evidence standard has been met, therefore, the above allegations are substantiated. A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D. A case management visit was conducted on 10/07/2024 due to violations observed during the investigation. See LIC809 on 10/07/2024. This report was reviewed with General Manager, Billy Mitchell and a copy of the report and appeal rights were provided. PAGE 3 OF 3. It was alleged that resident (R1) sustained multiple falls due to the lack of supervision from facility staff. Based on record review, R1 sustained multiple falls between April 2022 – December 2022. The falls were noted by staff in R1’s records to either be witnessed or unwitnessed falls. R1 sustained majority of the falls in his/her bedroom. R1’s service plans on 04/07/2022, 04/29/2022, and 09/09/2022 R1 did not require staff assistance with mobility, ambulation or escorting. R1’s service on 11/23/2022, indicated that R1 may require escorts with or without the use of assistive devices to and from meals, activities and/or common areas and the plan for staff to escort R1 with his/her walker to meals and activities due to being high fall risk. On 11/05/2022, staff recommend a 24/7 companion due to frequent falls to R1’s responsible party. There is no indication that the 24/7 companion was started. R1’s signed admission agreement states that the community is not designed to provide twenty-four-hour care. It’s stated that resident may remain in the community as long as the care needs and level of functioning are consistent with those of other residents and with the level of staffing and facilities offered in the community. The Department has investigated the above allegation. Based on record review and observation, the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager Billy Mitchell and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 7, 2024 · control 26-AS-20221215152806

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a) · Plan of correction due date: Oct 8, 2024

(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. Significant changes shall include but not be limited to: This requirement was not met as evidenced by: Based on record review and observation, the licensee did not ensure resident (R1) was re-evaluated and R1’s service plans were updated after falls resulting in the resident sustaining injuries due to the falls which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2024

Plan of correction: Licensee will submit a statement of understanding of the section cited (87463(a)) to LPA Dolores via email by POC due date of 10/08/2024.

Allegation investigated: Facility staff does not treat residents in a polite manner. Facility staff verbally abuse residents. Facility staff physically abuse residents.

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the findings for the above allegations. LPA met with General Manager Billy Mitchell and Resident Care Director Jocelyne Bailon Solache. On 04/04/2023, the Department received the complaint. On 04/12/2023, the initial complaint investigation was conducted. Documents were obtained to include the staff schedule and R1 - R7's physician's report, appraisal needs and services plan, and emergency contact form. It was alleged that the facility staff do not treat residents in a polite manner, facility staff verbally abuse residents and facility staff physically abuse residents. No names of specific residents or staff members were disclosed. PAGE 1. Unfounded On 04/12/2023, 7 residents were interviewed. Based on resident interview, 7 out of 7 residents did not have any complaints of staff not treating them politely. 7 out of 7 residents denied staff being verbally and physically abusive to them. 7 out of 7 residents denied the observation of staff being verbally or physically abusive to other residents. On 10/07/2024, 5 staff members were interviewed. Based on staff interview, 5 out of 5 staff member denied the observation or knowledge or staff not treating residents politely. 5 out of 5 staff denied the observation of staff being verbally or physically abusive to the residents. Based on record review, the Department did not receive any reports relating to these allegations. The Department has investigated the above allegations and based on interview, record review and observation the above allegations are unfounded, meaning the allegations are false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager Billy Mitchell and a copy of the report was provided. PAGE 2.the state’s words, verbatim · CDSS document, Oct 7, 2024 · control 26-AS-20230404153129

Allegation investigated: Staff pureed food without authorization. Staff not accommodating resident diet needs.

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegation. LPA met with General Manager Billy Mitchell and Resident Care Director Jocelyn Bailon Solache. On 07/14/2023, the Department received the complaint. On 07/21/2023, the initial complaint investigation was conducted. Documents were obtained to include facility’s roster from June – July 2023, resident (R1)’s physician’s report, physician’s orders, special diet form, physician communication fax, medical records, medication list, progress notes, weight analysis, service agreement from April – May 2023, and medication administrator record (MAR) from April – June 2023. PAGE 1. Unsubstantiated It was alleged that the facility staff pureed resident (R1)’s food without authorization from R1’s responsible party. On 07/21/2023, 2 staff members were interviewed. Based on staff interview, S2 states that when R1 returned from his/her doctor’s appointment, R1’s responsible party provided the paper that states there was a change in diet to puree from R1’s doctor visit sometime in April 2023. S2 states that R1’s responsible party knew there was a change in diet because R1’s responsible party provided the facility with the diet order. S2 states R1’s hospice team was also informed of the diet change. Based on record review, R1’s physician signed a “diet order and dietary communication” form on 04/21/2023 for a puree diet. It was alleged that the facility staff are not accommodating to R1’s diet needs by not providing R1 with a nutritional beverage. The review of records show that R1’s physician’s report dated in March 2023 states a special diet for a nutritional beverage. On 07/21/2023, 2 staff members were interviewed. Based on staff interview, S2 states that they did not follow-up with R1’s physician in March to obtain the physician’s order for the nutritional beverage. S2 states despite the physician’s report in March 2023 stating R1 has a special diet for a nutritional beverage, the facility still requires an actual order from the physician. S2 states that since they did not have an actual physician’s order for the nutritional beverage, they were unable to provide the beverage to R1. S2 states they received an order in June 2023. The Department has investigated the above allegations. Based on interview and record review the above allegations are unsubstantiated. An unsubstantiated finding indicated that although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. However, a case management visit was conducted on 10/07/2024 due to a violation observed during the investigation. See LIC809 on 10/07/2024. This report was reviewed with General Manager Billy Mitchell and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 7, 2024 · control 26-AS-20230714114133

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - deficiencies visit based on violations observed during 2 complaint investigations for complaint control number 26-AS-20221215152806 and 26-AS-20230714114133. LPA met with General Manger, Billy Mitchell and Resident Care Director, Jocelyne Bailon Solache. During the investigation for complaint control number 26-AS-20221215152806, it was found that on 07/09/2021, R1’s service plan was updated due to a change of condition in which R1 was moved from assisted living to memory care. On 04/07/2022, R1’s level of care increased from level 1 to level 2, which stated R1 was a low potential for falls to moderate potential for falls. On 04/29/2022, R1 went from a moderate potential for falls to a high potential for falls. On 11/23/2022, R1’s level of care increased from a level 2 to a level 10. Based on record review, resident (R1) did not obtain an updated physician’s report after any changes of conditions based on the re-evaluations and updated service plans. R1's physician's report was dated on 02/11/2021. R1 was admitted to the facility on 02/28/2021. R1’s service plans dated 07/08/2021, 04/07/2022, 04/29/2022, 09/09/2022, and 11/12/2022 were not signed by R1 and R1’s responsible party. The facility was unable to produce documents or proof to show the service plans were reviewed with R1’s and R1’s responsible party. On 04/30/2022, 06/24/2022, 07/05/2022, 07/06/2022, 08/09/2022, 09/23/2022, 10/07/2022 R1 sustained falls. Based on record review, it was not noted or indicated that R1’s physician was notified of the falls. SEE LIC809-C. During the investigation for complaint control number 26-AS-20230714114133, it was found that R1's physician's report dated March 2023 stated a special diet for a nutritional beverage. Based on interview with a staff (S2), it was stated that the facility did not follow-up with R1's physician for an order of the nutritional beverage after receiving the physician's report in March 2023. Based on interview and record review, R1 was not receiving the nutritional beverage until the facility received a physician's order from R1's physician in June 2023. Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with General Manger, Billy Mitchell and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 7, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Oct 14, 2024

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on record review and observation, the licensee did not ensure to obtain an updated physician’s report for resident (R1) after staff observed changes in R1’s conditions based on the re-evaluations and updated service plans, and did not obtain follow-up with R1's physician in a timely manner for an order for R1's nutritional beverage which poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2024

Plan of correction: Licensee will be implementing a high-risk meeting weekly with the leadership team to ensure processes are being followed. Licensee will submit a statement of understanding of the section (87465(a)(1)) to LPA Dolores via email by POC due date of 10/14/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(c) · Plan of correction due date: Oct 14, 2024

(c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement was not met as evidenced by: Based on record review and observation, the licensee did not ensure to review R1’s updated service plans with R1’s responsible party which poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2024

Plan of correction: Licensee will submit a written plan of the facility's process in ensuring the needs and services plans are reviewed and signed with the resident and/or their responsible parties. Licensee will send the written plan via email by POC due date of 10/14/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87563(b) · Plan of correction due date: Oct 14, 2024

(b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. This requirement was not met as evidenced by: Based on record review and observation, the licensee did not ensure to report R1’s falls to R1’s physician on 04/30/2022, 06/24/2022, 07/05/2022, 07/06/2022, 08/09/2022, 09/23/2022, 10/07/2022 which poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2024

Plan of correction: Licensee will conduct a internal audit to ensure resident's physician's are being notified of any changes of conditions and to review the facility's process in ensuring physician's are being notified of any changes of conditions. Licensee will submit a written result of the internal audit to LPA Dolores via email by POC due date on 10/14/2024.

Allegation investigated: Facility does not have enough staff to meet the needs of residents in care

Licensing Program Analysts (LPAs) Christine Dolores and Marcella Tarin arrived unannounced to deliver the finding of the above allegations. LPAs met with General Manager, Billy Mitchell. On 12/02/2022, the Department received a complaint alleging the facility’s Garden House section (aka memory care) does not have enough staff to meet the needs of residents in care. On 12/08/2022, the initial complaint investigation was conducted. The following documents were obtained for this investigation: Garden House schedule from 10/30/2022 – 12/10/2022, memory care resident roster, and 4 resident’s physician’s report, needs and services plan, and monthly task log. PAGE 1 OF 2. Unsubstantiated On 12/08/2022, 2 staff members were interviewed. Based on interview, in Garden House they normally have about 4 caregivers and 1 medtech per shift and NOC is normally 2 caregivers and 1 medtech. Staff from Assisted Living are pulled, if needed. It was stated that they utilize 1 agency staff in the AM shift at least 2-3 times a week and 2 agency staff in the PM shift at least 2-3 times a week. It was stated that agency staff are normally on the weekends. It was stated that if they are short staffed or have a call out, their staff either works doubles, leadership staff fills in to cover the shifts, or a staffing agency is contacted. 2 out of 2 staff stated the facility is constantly hiring, and the hiring of new staff is ongoing. Based on observation, on 12/08/2022 around 10:40AM, LPA Dolores entered the Garden House section. LPA observed 2 caregivers, 1 staff assisting with activities to a group of more than 10 residents, and 1 housekeeper on the floor. It was stated that 2 caregivers and 1 medtech was on break. Based on record review, there was 35 residents in memory care as of 12/08/2022. The facility’s Garden House schedule showed at least 3-4 caregivers and 1 medtech scheduled daily in the AM and PM. NOC shift shows at least 2 caregivers scheduled. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and Health Services Director, Jocelyn Bailon and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 26-AS-20221202123353

Allegation investigated: Staff member roughly handled resident in care Facility did not inform resident's family of change in resident's condition

Licensing Program Analysts (LPAs) Christine Dolores and Marcella Tarin arrived unannounced to deliver the findings of the above allegations. LPAs met with General Manager, Billy Mitchell. On 06/24/2022, the Department received the complaint. On 07/01/2022, the initial complaint investigation was conducted. The following documents were obtained for this investigation: resident (R1)’s physician’s report, service plan, communication log, medication administration record, identification and emergency contact information, incident report, staff schedule, memory care resident roster, and police report. PAGE 1 OF 3. Substantiated It was alleged that a staff member (S1) had roughly handled resident (R1) in care during the night of 06/13/2022 approximately around midnight. It was alleged that (S1) was upset that R1 was still awake around midnight and aggressively grabbed R1 from behind and pulled R1 up from his/her wheelchair. On 07/01/2022, 5 staff members were interviewed. Based on interview, S3 stated to be made aware of the incident between S1 and R1, on 06/15/2022, 2 days after the incident. S3 was notified by another staff (S2) of the observation between S1 and R1 the night of 06/13/2022. S3 stated that S2 gave R1 popcorn shortly after R1 had a fall, when S1 came into the TV room and “yanked” R1 up from his/her wheelchair, wrapped R1 under his/her shoulder saying it was time for bed. S2 attempted to defend R1 but S1 still continued to take R1 to bed. Based on review of the police records, a statement was taken from S2, who witnessed the incident. S2 stated to be in the dining room eating popcorn with R1, when S1 entered the room very upset that R1 was still up as it was 0030 hours. S1 approached R1 was behind and grabbed R1. S1’s arms were underneath R1 when S1 lifted R1 in an aggressive manger. S1 then forced R1 back and down into his/her wheelchair. Based on review of the police records, a statement was taken from R1. It was reported that R1 was in the dining room of the facility with S2 eating popcorn, when S1 entered the room upset and yelling at R1 for staying up. R1 reported that S1 approached him/her from behind and grabbed the victim from underneath the arms, lifted R1 up with S1’s hands across R1’s chest, inches below his/her throat and squeezed him/her. R1 reported that S1 had grabbed his/her right ring finger and attempted to fold it back. S1 wheeled R1 into his/her room and S1 slammed his/her up against the wall and put him/her to bed. Based on review of the police records, injuries were noted on 06/17/2022. R1 was observed with some bruising underneath both the left and right arms. Bruising was also noted on R1’s right forearm and right ring finger. PAGE 2 OF 3. After the incident, it was alleged that the facility did not informed R1’s family of a change in condition as R1 complained of pain and couldn’t move his/her arms and shoulders. It was alleged that the family was only notified of a fall that took place on 06/13/2022, and not the aggressiveness or pain until Friday, 06/17/2022 when bruises were discovered under R1’s arms. Based on staff interview, S3 stated that on 06/14/2022, 06/15/2022, and 06/16/2022 R1 complained of shoulder pain and requested for a PRN. S3 administered the PRN medication and monitored R1 for effectiveness of the PRN. On 06/14/2022, S3 did not notice any discoloration or bruising on R1 and informed his/her supervisor (S4) that R1 was complaining of shoulder pain. Based on interview with S4, S4 was made aware of incident at about 5:00PM on 06/15/2022. On 06/15/2022, S4 assessed R1 and observed R1 complained of pain on the left shoulder. S4 stated that R1 was complaining of so much pain that they couldn’t get R1’s shirt up to observe. S4 faxed the doctor. On 06/16/2022, S4 called the family and stated to have notified the family of R1’s shoulder pain and headache and suggested to R1’s responsible party to take R1 to the doctor to make sure. Based on review of R1’s records, it was indicated that on 06/16/2022 staff spoke with R1’s responsible party that R1 hasn’t been sleeping well at night. There was no note that staff informed R1’s responsible party of any complaints of pain starting from 06/14/2022, when R1 first complained of shoulder pain. Based on record review and interview, S1 was moved to assisted living and no longer assigned to the memory care unit. The Department has investigated the above allegations. Based on interview and record review the preponderance of evidence standard has been met, therefore, the above allegations are substantiated. Deficiencies were cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with General Manager, Billy Mitchell and Health Services Director, Jocelyn Bailon and a copy of the report and appeal rights were provided. PAGE 3 OF 3.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 26-AS-20220624162710

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Sep 20, 2024

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not ensure resident (R1) was free from abuse by staff (S1) who handled R1 roughly on the night of 06/13/2022 which poses an immediate, health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 19, 2024

Plan of correction: Licensee will conduct an in-service training on the section cited. Licensee will submit the in-service training record to LPA Dolores via email by POC due date of 09/20/2024.

From the deficiency page — Deficiency type: Type A · Section cited: ILS 87463(b) · Plan of correction due date: Sep 20, 2024

(b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not ensure to immediately bring to the attention of resident (R1)’s family or responsible party of R1’s shoulder pain which poses an immediate health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Sep 19, 2024

Plan of correction: Licensee will conduct an in-service training on the section cited. Licensee will submit the in-service training record to LPA Dolores via email by POC due date of 09/20/2024.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Marcella Tarin and LPA Christine Delores conducted an unannounced annual inspection visit at 9:45AM and met with General Manager (GM) Billy Mitchell and Health Services Director, Jocelyn Bailon. LPAs toured the facility inside and out with the General Manager to include the living room, dining room, kitchen, resident bedrooms, bathrooms, and exterior. Facility temperature maintained between 70 to 75 degrees F. Facility staff are fingerprint cleared and associated to facility. All emergency exits were observed to be clear of obstruction. LPAs toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature maintained at 35 degrees F and freezer maintained at -5 degrees F. The exterior of the facility was also inspected. No toxins, chemicals or items that can pose a danger to residents observed. LPA Tarin toured 7 resident bedrooms. 7 out of 7 resident bedrooms had functioning lights, storage space for personal belongings, clean bedding, a chair, lamp and dresser/table. LPA measured hot water temperature, range of 106.7 to 115.7 degrees F for 7 out of 7 resident bathrooms. The facility was equipped with smoke and carbon monoxide detectors. Fire extinguishers were last serviced on 6/30/2024. LPA observed the facility first aid kit and it was observed to be complete. The facility fire/earthquake drill log was reviewed and drills are being conducted quarterly. The last fire drill was conducted on 6/30/2024. Facility has emergency disaster plan. LPA reviewed 7 residents Centrally Stored Medication and Destruction Records (CSMDR). LPA observed 7 out of 7 CSMDRs are complete with all medications accounted and documented. LPA observed the medication storage area was locked and inaccessible to residents in care. Please see LIC 809-C. LPA reviewed 5 out of 5 resident records. LPA observed 5 out of 5 resident records as complete to include a medical assessment, TB result, updated appraisal/needs and services plan, identification and emergency contact information, personal rights, and consent forms. LPA reviewed 6 out of 6 staff records. LPA observed 4 out of 6 records as complete to include fingerprint clearance, health screening, TB result, and personnel record. Staff (S1) and (S4) records were observed as incomplete. S1 file was not available for review by LPA. GM states corporate has the file and does not have the physical file in the facility. S1 does not have a health screening and TB result. GM states a plan to obtain a health screening and TB result. S4's file does not contain a health screening and TB result. GM states they have requested the health screening and TB result and are awaiting the documentation. 6 out of 6 staff records did not contain documentation for annual training. GM states he has the training records on file in an email and will email staff training records to LPA Tarin by morning of 9/20/2024. LPAs advised GM that all personnel records must be maintained at the facility and available for review by the licensing agency. During visit LPA obtained GM's administrator certificate and resume. Deficiencies were cited today per California Code of Regulations, Title 22. See LIC809-. Exit interview was conducted with GM. This report was provided to GM and appeals rights were provided.the state’s words, verbatim · CDSS document, Sep 19, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - other visit. LPA met with Executive Director (ED) Kim Golden. During visit, a complaint report for complaint control number: 26-AS-20220404161647 was amended. The amended report was reviewed and handed to the ED. On 06/12/2024, the facility was issued a civil penalty for a staff member working in the facility without a criminal background check clearance. On 06/12/2024, the wrong civil penalty assessment form was generated. During today visit, the correct civil penalty form (LIC421BG) was reviewed and signed by the ED. LPA obtained the hard copy of the LIC421BG. ED obtained a copy of the signed LIC421BG. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director Kim Golden and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 24, 2024

Type of visit: Office

On 06/13/2024 San Bruno Regional Office - San Jose Unit conducted a non-compliance conference meeting with Vice President of Operations Kim Golden, Legal Council (Hansen and Bridges) Joel Goldman, Vice President of Care Teri Moore-Showalter, Regional Director of Health Services Erika Hughes, and Garden House Director Jocelyne Bailon. Present in the meeting were Regional Manage Vivien Helbling, Licensing Program Manager Jackie Jin, and Licensing Program Analyst Christine Dolores. During the non-compliance meeting, the following serious violations were discussed: 87211(a)(2) Reporting Requirements, 87466 Observation of Resident, 87468.1(a)(2) Personal Rights of Residents in All Facilities, 87463(a)(3) Reappraisals, 87468.1(a)(3) Personal Rights of Residents in All Facilities, 87355(e)(2) Criminal Record Clearance, 87355(e)(1) Criminal Record Clearance, and 97705(f)(2) Care of Persons with Dementia. During this meeting, the compliance plan was developed and discussed with the licensee which includes more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations: https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers. During this meeting, an additional deficiency was issued as per California Code of Regulations, Title 22 following deficiencies found during case management visits and complaint investigations: on 05/29/2024, licensee and Administrator failed to report a serious injury and resident's death within 24 hours to Licensing. See LIC809-D for more information. Page 1 of 2. On 01/31/2023 and 12/08/2022, licensee and Administrator failed to associate 4 staff members to the facility's roster prior to staff members starting work resulting in a repeat violation within a 12 month period. On 06/12/2024 and 12/08/2022, licensee and Administrator failed to obtain a criminal record clearance for 2 staff members prior to the staff members starting work. On 01/16/2024, licensee and Administrator failed to ensure a resident's reappraisal was updated after returning to the facility from the hospital. The current Administrator's last day at the facility is 06/14/2024. An additional Civil Penalty for violation resulting in serious injury is pending review. This report was reviewed with Vice President of Operations Kim Golden, Legal Council (Hansen and Bridges) Joel Goldman, Vice President of Care Teri Moore-Showalter, Regional Director of Health Services Erika Hughes, and Garden House Director Jocelyne Bailon. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 13, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(2) · Plan of correction due date: Jun 14, 2024

(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on interview, record review, and observation the Administrator failed to exhibit the knowledge of applicable laws, rules and regulations resulting in serious violations which poses an immediate health safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 13, 2024

Plan of correction: Licensee will ensure that immediately, Administrator will be trained regarding Administrator Qualification, Duties and Responsibilities. Temporary Administrator is in place. Deficiency was corrected.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - deficiencies visit due to a violation observed during a complaint investigation. LPA met with Vice President of Operations, Kim Golden and General Manager Kippie Castronovo. During a complaint investigation for complaint control number 26-AS-20240524084602, it was found a staff member (S1) was working in the facility without obtaining a criminal record clearance. Based on review of S1's file, S1 started at the facility of 05/17/2023 and ended employment on 05/2024. LPA reviewed the Department's Guardian Background Check System, which does not show that S1 has a criminal record clearance from the Department. A deficiency was cited during today’s visit, see LIC 809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500), for staff (S1) working at the facility without fingerprint clearance. See LIC421M. This report was reviewed with Vice President of Operations, Kim Golden and General Manager Kippie Castronovo and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Jun 13, 2024

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by: Based on interview and record review the licensee did not obtain a criminal record clearance for staff (S1) prior to S1 starting work which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 12, 2024

Plan of correction: Licensee will submit a written plan regarding the section cited to LPA Dolores via email by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit. LPA met with General Manager, Kippie Castronovo. During today's visit, LPA was verbally informed of a resident (R1's) death on 05/25/2024. Based on record review and interview, the facility did not notify the Department of R1's death within 24 hours of the occurrence date. R1's documents were requested by tomorrow (05/30/2024) morning: physician's report, needs and services plan, identification and emergency information, and progress notes for May 2024. Documents were obtained during visit to include the incident report, police case number, and coroner's case number. This case management visit will be pending investigation. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with General Manager, Kippie Castronovo and a copy of the report and appeal was provided.the state’s words, verbatim · CDSS document, May 29, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(2) · Plan of correction due date: May 30, 2024

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not ensure to report the resident (R1)'s death and incident to the department within 24 hours which poses / posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 29, 2024

Plan of correction: Licensee will submit the training documentation to LPA Dolores via email by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit. LPA met with General Manager, Kippie Castronovo. During visit, LPA obtained a copy of resident (R1)'s records to include: face sheet, identification and emergency information, consent forms, physician's report, ID, needs and services plan, and progress notes. This case management visit will be pending investigation. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Kippie Castronovo and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 29, 2024

Allegation investigated: Resident was found on the floor of apartment covered with ants Resident was severely neglected resulting in injuries after sustaining a fall

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding for the above allegations. LPA met with Interim General Manager, Kippie Castronovo. On 08/28/2023, the Department received a complaint alleging that a resident (R1) was severely neglected resulting in injuries after sustaining a fall and was found on their apartment floor covered with ants. On 08/30/2023, the initial complaint investigation was conducted. The following documents were obtained to include resident (R1)’s medical records, physician’s report, service plan, progress notes, admission agreement, staff schedule from July 30, 2023 to September 2, 2023, and resident check-ins. PAGE 1 OF 3. Substantiated PAGE 2 OF 3. On 08/08/2023, R1 was admitted to the hospital after a fall. The review of R1’s medical records noted that R1 was not safe to go back to the facility. R1’s active problems included impaired mobility and activities of daily living and muscle weakness. However, since R1 refused to go to a skilled nursing facility R1 was referred to Home Health. On 08/18/2023, the hospital case worker spoke with two staff at the facility and advised of the discharge and referral to home health. On 08/19/2023, R1 was discharged back to the facility. Based on the facility's protocols, resident was placed under alert charting for return from hospital and staff were to monitor R1 for 72 hours. Based on staff interview, 6 out of 6 staff stated that R1 was independent. Staff was unaware that R1 was on a 72-hour check and stated that staff was not checking on R1 as they were supposed to. Based on record review, there is only documentation that staff noted R1’s condition on 08/19/2023 and 08/21/2023. There is no documentation that R1’s condition was monitored on 08/20/2023. During staff interviews, it was also observed that R1 was not feeling well on 08/24/2023, however, there was no documentation of communication between staff nor of R1’s condition that day. On 08/27/2023, at 0750 hours, staff found R1 on his/her bedroom floor with dried blood and injuries to his/her body including a golf size bump on his/her forehead. Staff called 911 and R1 was transported to the hospital where it was noted that R1 had a bump on his/her forehead with redness and discoloration on the right side of his/her right eye, skin tear on his/her right elbow and on his/her hands and knees. Based on interview, R1 reported to be getting ready for bedtime, when R1 fell and hit his/her head on the night stand. R1 was on the floor and tried calling out for staff help, however, no one responded. R1 was not checked by the staff throughout that night and was found the morning of 08/27/2023 after calling out for help. Based on staff interview, when R1 was found on the floor, R1 had ants on his/her body. PAGE 3 OF 3. The review of records shows that R1’s service plan was updated on 08/20/2023. The updated service plan did not include any diagnosis and specific needs relating to R1’s condition after being discharged from the hospital on 08/19/2023. R1’s service plan also did not indicate the need for assistance in ambulation, despite R1’s hospital discharge paperwork stating that R1 had impaired mobility and activities of daily living (ADLs), and muscle weakness. R1 was noted to be a moderate fall risk, however, the facility did not implement any additional measures to ensure R1’s safety in the facility knowing R1 is a fall risk. There is also no documentation of any refusal of care. According to R1’s residency and service agreement, the facility’s responsibility was to regularly observe the residents health status to identify social and health care needs and provide the residents with needed consultations regarding social and health related issues. In the agreement, it was also stated that “the resident’s rights shall not be limited in any way by us or team members, except where it may be necessary for the health and safety of the residents.” Based on observation from the Department’s unannounced visits on 08/03/2023 and 11/09/2023, LPA Dolores observed ants on the floor of resident (R2)’s bedroom and ants along the walls of the Business Office Director’s office. Based on interview, the facility has ongoing issues with ants and currently has a contract with a pest control to eliminate the issue. The Department has investigated the above allegations. Based on record review, interview and observation conducted the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are being cited. See LIC9099-D. An immediate civil penalty of $500.00 is being assessed against the facility today for violation resulting in serious injury to a resident in care. An additional Civil Penalty for violation resulting in serious injury is pending review. This report was reviewed with Kippie Castronovo and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Jan 16, 2024 · control 26-AS-20230828135509

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jan 17, 2024

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidence by: Based on interview, record review, and observation the licensee did not ensure resident (R1) was checked on regularly for 72 hours after being discharged back to the facility from the hospital. On 08/27/2023, resident was found on the floor with injuries to include a golf size bump on the forehead and skin discoloration on the eye, elbow, hands and knees. This poses/posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 16, 2024

Plan of correction: Licensee will provide an in-service training for all staff to include the topic of observations and documenting resident's conditions and monitoring resident's for 72 hour checks. Licensee will submit the training documentation to LPA by POC due date of 01/17/2024. Licensee will also submit a plan to provide an all-staff training for the remainder of the staff who are not present today. Licensee will submit the plan to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jan 17, 2024

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on interview, record review, and observation the licensee did not ensure resident (R1) was accorded a healthful and comfortable accommodation due to being found on the floor with ants on R1’s body which poses/posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 16, 2024

Plan of correction: Licensee will provide an in-service training on topics to inlcude sanitation, cleanliness, and resident's health and safety. Licensee will submit the in-service training to LPA by POC due date of 01/17/2024. Licensee will submit the facility's pest control contract to include any documentation on the ants issue. Licensee will submit the documentation to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a)(3) · Plan of correction due date: Jan 17, 2024

(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. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or … This requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not ensure resident (R1)’s reappraisal was accurate and documented R1’s diagnosis and changes to the resident’s condition after returning to the facility from the hospital on 08/19/2023 which poses/posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 16, 2024

Plan of correction: Licensee will provide an in-service training with the facility's directors, team nurses, and care staff to go over re-appraisals when the resident returns to the community. Licensee will submit the in-service training to LPA by POC due date of 01/17/2024.

Allegation investigated: Facility allowing unauthorizied visitors

THIS IS AN AMENDED REPORT FROM 01/16/2024. Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegation. LPA met with Executive Director, Kim Golden. On 04/04/2022, the Department received a complaint alleging that the facility did not stop resident (R1)’s relatives from visiting R1, therefore, allowing an unauthorized visitor. It was alleged the incident happened around January 2021 – June 2021. On 04/13/2022, the initial complaint investigation was conducted. The following documents were obtained to include resident (R1)’s residency and service agreement, physician’s report, appraisal/needs and services plan, power of attorney (POA) documents, and progress notes. SEE LIC9099-C. Unfounded On 04/13/2022, the Administrator was interviewed. Based on interview, the facility did not have any current residents who have restraining orders or any unauthorized visitations. It was stated the residents have a right to see who they want and can have visitors if they consent to it unless there is a restraining order. It was stated that if a resident’s POA does not want a resident to see a certain visitor, the resident still has their right to consent to the visitation. Based on interview, R1’s POA did not want anyone to see R1. It was stated that R1 always wants to see his/her relative and can see his/her realize if he/she consents to the visitation. Staff (S2) stated R1's responsible party verbally stated they did not want R1's relative to visit, however, R1 always consented to seeing R1's relative. Based on record review, there is no documentation that R1 had any restraining orders nor was the facility provided a list of unauthorized visitors from the resident and/or resident's responsible party. Based on review of R1's POA (power of attorney) documentation, there is no documentation that allows R1's POA to restrict visitations. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded meaning the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Kim Golden and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 16, 2024 · control 26-AS-20220404161647

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - other visit. LPA met with Interim General Manager, Kippie Castronovo. The purpose of the visit was to deliver an amended LIC809-D that was issued on 01/31/2023. LPA reviewed the LIC809-D with IGM. IGM signed the amended LIC809-D and was provided a copy of the LIC809-D. This report was reviewed with Interim General Manager (IGM), Kippie Castronovo and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 15, 2023

Allegation investigated: Facility staff did not seek medical attention for resident in a timely manner.

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open the initial complaint investigation. LPA met with Garden House Director (GHD) Jocelyn Bailon. On 11/02/2023, the Department received a complaint alleging facility staff did not seek medical attention for resident (R1)’s in a timely manner. It was alleged, R1 can hardly walk somedays because R1’s bunions are red and they hurt. On 11/09/2023, the initial complaint investigation was conducted. The following documents were obtained for this investigation to include R1’s physician’s report, needs and services plan, preplacement appraisal information, identification and emergency information, progress notes, and POA documents. SEE LIC9099-C. Unfounded On 11/09/2023, 4 staff members were interviewed. Based on interview, the facility staff was unaware of any concerns regarding R1’s feet and bunions. 4 out of 4 staff states R1 has never complained of any pain. 4 out of 4 staff denied any observation of redness on R1’s feet. 4 out of 4 staff state R1 is constantly walking around Garden House and has never complained of any pain. S4 states to observe R1 was limping one day and when asked if R1 was in pain, R1 denied any feeling of pain and continued to walk around Garden House. 4 out of 4 staff state R1’s family and/or visitor has not addressed any concerns regarding R1’s bunions and feet. On 11/09/2023, 1 witness was interviewed. Based on interview, R1 has been complaining that his/her feet were hurting for “quite a while”, however, the facility was not informed of that information when R1 moved in. Based on records reviewed, there was no indication of medical concerns relating to R1’s bunions and/or feet. There was also no indication R1 complained of any pain which may prompt facility staff to seek medical attention. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded meaning the allegation is false could not have happened and/or is without a reasonable basis. This report was reviewed with Garden House Director, Jocelyn Bailon and a copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 9, 2023 · control 26-AS-20231102093634