Mirabel Lodge

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

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management Legal/ Non-compliance and met with administrative assistant, Lisa DiBartolo. LPA was following up on items that were concerning and ensure compliance with Non-Compliance Conference dated 2/4/26: - Timely Medical Attention: Facility failed to seek timely medical attention for residents. During today's visit, LPA reviewed incident report logs received for the last quarter that confirmed that they were submitted within 7 days as indicated per regulation. Also, staff have received timely medical and dental training to assist residents in care. - Documentation: Facility did not ensure that observations of residents' condition and care are documented. The facility provided LPA with resident's care notes for review that are documented in a centralized electronic application called Quiltcare where staff documents residents' daily care notes observations including bowel movement, hygiene, community integration, cognition activity, review stress triggers, transfers, teeth brushing, showers, food and fluid intake. The application allows staff to report incidents which alerts directly the Licensees for further processing and reporting by giving them the option to submit reports urgent or informational matter in English or Spanish as well as dictation options. Continued on LIC809C... Continued from LIC809... - Communication with Licensing Department: Discussion around the regulatory allowance of CCL representatives to interview staff. LPA spoke with staff (S2 & S3) who stated that they are allowed to talk to CCL representatives when they request it. - Medication - Facility does not currently have a Medication Technician on all shifts and is leaving PRN medication pre-poured for the NOC shift. Today, the facility provided an updated LIC500 along with medication training records that confirms all Medication Technicians (S1, S2, S3, S4, S5, S6 & S7) has received medication training and confirming that there is a designated medication technician at night. On 7/28/26 a pharmacy vendor conducted medication audit at the facility to review medication management. No deficiencies cited during today's inspection. Exit interview conducted with administrative assistant and copy of this report was given.the state’s words, verbatim · CDSS document, Jul 30, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marisol Cuadra arrived unannounced to conduct this Case Management Visit to follow up on incident report submitted to CCL. LPA met with Administrative assistant Lisa DiBartolo. Incident Report (SIR) was received on 6/11/26. According to SIR, on 6/5/26 resident (R1) at approximately 8:10 a.m, R1 exited the facility through the front gate while a visitor was entering, Staff became aware the resident was no longer on the premises and immediately initiated a search of the facility and surrounding area. At approximately 8:31 a.m, Sonoma County Sheriff's Office notified the facility that the resident had been located. R1 was assessed by EMS, no injuries were identified, and R1 returned to the facility. Administrator notified responsible party as required. R1 is currently being monitored for safety and well being. Facility is actively researching and evaluating technological solutions that may provide staff notification when residents identified as being at risk for elopement approach exit points. Any solution implemented will be consistent with Title 22 requirements, resident rights, and the resident's assessed needs. Warning signs are posted on both sides of the front gate instructing visitors to ensure that no resident exits the facility through the gate with them unless authorized and accompanied by staff. Staff were given specific instructions to watch the resident of elopement risk at all times. During today's visit, LPA requested and reviewed R1's records including their physician report (LIC602), care plan and facility elopement policy. Per R1's physician report dated 2/15/24, R1 does not have a diagnosis of dementia, R1 is able to leave the facility unassisted and communicate their needs. R1's care plan dated 6/6/26 has been updated to indicate exit seeking behaviors, but it has not been signed by R1's responsible party. LPA reviewed the facility elopement policy, which determines that the facility staff followed their policies and procedures regarding AWOL/Elopement including the identification of risk for each resident after any significant change in condition. No deficiencies found during today's visit. Exit interview conducted with administrative assistant and copy of this report was given.the state’s words, verbatim · CDSS document, Jun 15, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct this Case Management Visit and get signatures on an amended report dated 5/20/26 and civil penalties issued the same date. LPA met with Licensee Alex Varshavsky and explained the reason of the visit. The document requires amending because civil penalty in the amount of $1000 will be removed due to documentation provided by the facility was submitted the same day as proof of correction of scheduled training to be conducted on 5/28/26, which it was confirmed that training was completed. Amended document deletes reference to civil penalty. LPA removed the civil penalty. Report was amended and signed today, 6/2/2026. No citations were issued during this visit.the state’s words, verbatim · CDSS document, Jun 2, 2026

Type of visit: POC

***Amended...On 5/20/26 Licensing Program Analyst assessed Civil Penalties (CP) in the amount of $1000.00 for failure to correct deficiencies. During that visit, LPA was provided with scheduled training date of 5/28/26 and citation was cleared. Today, LPA returned to remove civil penalties in the amount of $1000. Licensee was advised that moving forward if they feel like that can't meet timeline for POC to communicate with the department to request an extension of their POC timely. Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct this Proof of Correction Visit to follow up on plan of correction not submitted. LPA met with administrative assistant Lisa DiBartolo. On 4/24/26 LPA issued a citation for substantiated complaint findings on complaint#21-AS-20251224093221 deficiency of regulation 87465(a)(1). The plan of correction required facility to arrange for personal rights training and what medical professionals are best suited to assess residents’ needs with local ombudsman by plan of correction due date 4/24/26. Training to take place no later than 5/8/26, licensee to attend training as well as all care staff and Administrative Assistant. However, as of today, 5/20/26 CCL has not received proof of staff training on regulation 87465 (a)(1) which was due 5/1/26. Additionally, as of today 5/20/26, CCL has not received proof of a Personal Rights training appointment set with the ombudsman or proof of completed Personal Rights training with the ombudsman which was due no later than 5/8/26. On 4/23/26 facility submitted to CCL a “Written Medical Attention & Chain of Command Policy”. However, as of today, 5/20/26 CCL has not received proof of staff training on regulation 87466 “Observation of Resident Policy.” which was due 5/1/26. During today's visit, LPA learned that training is scheduled with Ombudsman for 5/28/26, but the facility failed to notify CCL timely. Therefore, a civil penalty in the amount of $100 per day for ten (10) days, from 5/11/26 through 5/20/26, are being assessed for failure to correct deficiency of regulation 87465(a)(1) for a total of $1000. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, May 20, 2026

Allegation investigated: Facility is in disrepair Call button is in disrepair resulting in resident's needs not being met Personal rights

Licensing Program Analyst (LPA) Coppo arrived unannounced to deliver findings on the above complaint allegations. LPA met with Administrative Assistant Lisa DiBartolo and Licensee Alex Varshavsky. Complaint alleges facility is in disrepair. Complainant states that there are no towel racks on which residents can hang their towels. During investigation, LPA observed hand towel racks approximately 6 inches long present in bathrooms of residents. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Complaint alleges personal rights. Complainant states that staff do not provide resident (R1) with certain food items such as butter or salt and pepper. Review of R1’s medical assessment did not indicate a special diet. During investigation, LPA observed a butter margarine blend present in facility kitchen. LPA also Continued on 9099C... Unsubstantiated Continued form 9099... observed salt and pepper. During investigation, Spanish speaking LPA Cuadra attempted to conduct interviews with four (4) staff. Of the four (4) staff, one declined to interview, one agreed to be interviewed, and two (2) did not respond to LPA’s attempts to interview. During investigation, LPA Coppo conducted interviews. Four (4) out of four (4) staff report that residents can ask for whatever they like as far as food and they then ask the kitchen staff to get it. Four (4) out of four (4) staff report that to the best of their knowledge the facility has never run out of butter or salt and pepper. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Complaint alleges resident call button in disrepair resulting in residents needs not being met. Complainant alleges that resident (R2) urinated on the floor in their bedroom due to not receiving help from staff when using call button pendant. During investigation, LPA observed R2’s call button pendant to not work. LPA pushed call button pendant, waited for 11 minutes, but no staff ever showed up. Additionally, when LPA pushed call button pendant LPA did not hear a sound notification go off or alert to staff. During initial visit to facility, LPA observed call button affixed to the wall behind a television, not easily accessible. During subsequent visit to facility, LPA observed the call button that was affixed to the wall had been moved from behind the television to a more accessible spot on the wall. During investigation, Spanish speaking LPA Cuadra attempted to conduct interviews with four (4) staff. Of the four (4) staff, one declined to interview, one agreed to be interviewed, and two (2) did not respond to LPA’s attempts to interview. During investigation, LPA Coppo conducted interviews. Four (4) out of four (4) staff report that R2 does have incontinence issues but could not remember if R2 had ever urinated on the floor in their room. One staff indicated that R2 does have accidents but did not recall exactly where R2 urinated, commenting that the only problem is when “R2 does not urinate in the toilet.” So, LPA did determine that R2’s pendant was in disrepair, staff did not respond to it, and the call button for the room, at that time, was not easily accessible as it was located behind a television. However, LPA did not obtain a preponderance of evidence showing that the broken pendant resulted in resident’s care need not being met. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with licensee and copy of this report given.the state’s words, verbatim · CDSS document, May 11, 2026 · control 21-AS-20260212082027

Allegation investigated: Facility not meeting resident care needs

Licensing Program Analyst (LPA) Coppo arrived unannounced to deliver findings on the above complaint allegations. LPA met with Administrative Assistant Lisa DiBartolo and Licensee Alex Varshavsky. Licensing Program Analyst (LPA), Coppo conducted an investigation into the allegation of “facility not meeting residents care needs." LPA Coppo and LPA Contrerras conducted interviews with nine (9) facility staff, the licensee/administrator, four (4) outside parties who had knowledge of resident's (listed as R1) care needs, reviewed facility records, ER discharge notes, and physician notes as well as other documentation related to R1. The following information was obtained. Complaint alleges that resident, R1 had a scheduled phone appointment on 12/22/2025, which was missed due to facility not answering the phone. A voicemail was left but not returned. The following day Continued on 9099C... Substantiated Continued from 9099... resident was sent to the hospital for being “warm to touch.” Complainant expressed concern that R1 is non-verbal with dementia, is unable to verbalize pain and was sent to the emergency room alone. Per file review, a record of R1’s temperature was not documented. Review of the After Visit Summary indicated that resident was diagnosed with a Urinary Tract Infection and Dental Caries with after care instructions indicating that they were to follow up with their medical doctor in “1 day (around 12/24/2025)” and were to “see a dentist as soon as possible for evaluation for tooth extraction.” Facility was unable to provide documentation showing that there was a follow-up with their doctor within one day, as instructed in that after visit summary, or that an appointment was sought by the facility for a follow-up with a dentist. A follow up visit was conducted on 1/6/2026 with R1’s Nurse Practitioner. Per Nurse Practitioner’s order R1 has “gingivitis (gum inflammation) and also periodontitis - inflammation around the root of the molar, which is "cracked” and defined that treatment will be an extraction or root canal under anesthesia. The doctor’s order went on to say that as an intermediate step, have the visiting dental hygienist conduct a thorough cleaning of R1’s teeth and gumline. Order instructed facility that if R1 still has tenderness, inflammation, poor appetite, mouth pain, or behavior changes 1-2 weeks after the cleaning, R1 will likely require further evaluation and treatment with extraction or root canal. Finally, the facility was instructed to “provide mouth hygiene on a daily basis; use Orajel on toothbrush first to numb the gum line, then use Sensodyne toothpaste paying special attention to the upper right molars.” Interviews with five (5) staff indicated they assist R1 with teeth brushing but three of five were unaware of any special instructions with the remaining two not having a response to the question. Individual staff noted that R1 bites their toothbrush when staff are trying to brush their teeth and swallows the water with two staff indicating it is difficult for the resident to open their mouth. Based on review of R1’s file, the care plan was not updated following the emergency room visit or the nurse practitioner’s order to reflect changes in R1’s care needs. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.the state’s words, verbatim · CDSS document, Apr 17, 2026 · control 21-AS-20251224093221

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Apr 24, 2026

87465 Incidental Medical and Dental Care (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 not met by licensee as evidenced by: Based on LPA record review and interview, the licensee did not comply with the section cited above in that staff did not provide the care that was required for R1, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 17, 2026

Plan of correction: ***Amended...LPA returned to remove civil penalties in the amount of $1000. Facility to arrange for personal rights training and what medical professionals are best suited to assess residents needs with local ombudsman by plan of correction due date. Training to take place no later than 5/8/26, licensee to attaned training as well as all care staff and Administrative Assistant. Additonally, facility to submit to CCL a written defined policy outlining the facility protocols for those incidents where residents need medical attention as noted by after visit summaries, Emergency Medical Services personnel or reports, doctors or any medical professional reports or suggestions, and staff observation. Written policy to include chain of command for reporting and identification of staff repsonsible for each action idenified in chain of command. Written policy due by plan of correction due date. Lastly, facility to submit proof of staff training on Observation of a Resident, regulation 87466 and the chain of command policy. Training to be completed no later than 5/1/26.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Lisa DiBartolo, Administrator Assistant (AA). Licensee Alex Varshavsky was also present. Licensee Administrator certificate 7019479740 expires 7/15/26. Facility currently has thirty one (31) residents in care five (5) of which are currently on hospice. LPA went over staff associated to facility with AA. Staff (S1) was found to have fingerprint clearance but not associated to the facility (deficiency cited, see 809D). At approximately 9:30am LPA and licensee toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food in the kitchen was found to be stored in a safe manner with open items covered and labeled with opened dates present. Facility has a food storage room. Food storage room there are pesticides and toxins present (deficiency cited, see 809D). All other cleaning products and laundry soaps are located in the dedicated cleaning closet or laundry room. All bedrooms were equipped with lighting. Rooms #2, #3, #15, and #17 need a chair and #11 and #12 need another chair as they are a shared room. Rooms #14, #4, #6, #9, needs a chest of drawers and #12 needs another a chest of drawers as it is a shared room (deficiency cited, see 809D). Shower in room #15 and room #4 need a grab bar (deficiency cited, see 809D). All other resident bathrooms had required bath mats and grab bars. Facility had common towels present in shared rooms and all but two (2) other resident rooms did not have paper towels present. Per licensee, facility does not keep Continued on 809C... Continued from 809... paper towels in resident rooms purposely, licensee claims residents flush them down the toilets (deficiency cited, see 809D). Room #!1 has a broken vanity cabinet door and room #2 has broken blinds. Internal courtyard has deck planks that do not meet, leave holes present such that one can see through to the ground, per licensee these planks were just repaired. However, wood panel just outside of room #14 leading to internal courtyard is splintered, bows and bends with pressure and has black substance present. Facility food storage room has a floor that bows and bends when pressure is applied (deficiency cited, see 809D). Triple antibiotic ointment with active ingredients of Bacitracin Zinc 400 units, Neomycin Sulfate 3.5mg, Polymyxin B Sulfate 5000 units was found by LPA and licensee in room #20 (deficiency cited, see 809D). Extra hygiene products and linens were available. Water temperature in sinks measured at 118.2 degrees F in the kitchen, 110.6 degrees F in room #20, 106.9 degrees F in the common bath/shower room, 108.2 degrees F in room #11, and 106.2 degrees F in room # 15 all of which are within the allowable range of 105 to 120 degrees F. Facility has another bathroom used by staff only. Fire extinguishers were last inspected 03/18/26. Sprinklers were tested and serviced by vendor on 3/18/26 all systems pass. Smoke detectors located throughout the facility are serviced by vendor, all systems passed, last service date was 6/2/25. Carbon monoxide detector present in facility. LPA and licensee tested detector and found it functional and operational. Facility’s last quarterly disaster drill was conducted on 01/20/26. Facility has a backup generator for use during a power outage. At approximately 11:00am LPA, licensee, and Administrator Assistant conducted a spot check of medication and medication records. Medication is centrally stored in two (2) locked medication carts. The following errors were found for resident (R1): prescribed Mentol-Zinc Oxide, hydrocortisone 1% cream, and Miconazole 2% were listed on the current physician's orders but not present on the Centrally Stored Medication log (CSML) (deficiency cited, see 809D). Morphine 20mg was on the CSML but the wrong instructions were listed. Instructions on physician's orders were: take by mouth every hour as needed for pain or shortness of breath, but CSML listed for it be administered "2X per day" (deficiency cited, see 809D). Senna 8.6 mg bubble Continued on 809C(2)... Continued from 809C... pack was stared 4/2/26 to be administered on Mondays and Thursdays 1 tab 2 times per day. Total tabs in bubble pack on 4/2/26 was 31 and today 22 pills remain, so facility is under by 1 tab (deficiency cited, see 809D). At approximately 2:00pm LPA conducted a review of eight (8) out of thirty-one (31) resident files. R1 had a medical assessment dated 12/2024. Per AA, facility has been requesting an updated medical assessment since 3/2026. LPA reviewed documentation of requests. Request dated 4/8/26. LPA advised that request for an updated medical assessment should begin no later than the same month in which the update is due and if the facility makes an attempt to get an update be sure document the request, such a a fax transmission or copy of email. All other documentation present. No deficiencies cited. LPA and Licensee discussed Infection Control Plan. LPA and Licensee discussed Emergency Disaster Plan. AA confirmed no updates needed. LPA will return at a later date to complete annual inspection and issue citations for those items identified in today's report as well as any other deficiencies identified when LPA returns to complete annual inspection. Exit interview conducted with licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, Apr 17, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced to conduct interviews in relation to open complaint #21-AS-20260212082027. LPA greeted by caregiver. Lisa DiBartolo, Assistant Administrator (AA) arrived later. Licensee notified of LPA visit by AA. Upon entering facility, LPA observed medication room window to be open and unlocked; no staff present in medication room. Keys to medication room door left unattended and accessible to residents in care. Additionally, prescription Thick-It for resident (R1) was in kitchen window accessible through kitchen window, accessible to residents in care (deficiency cited, see 809D). LPA discussed with AA importance of keeping medications inaccessible to residents and keeping keys to medication room inaccessible to residents in care. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with AA and a copy of this report was given.the state’s words, verbatim · CDSS document, Apr 3, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Apr 6, 2026

87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on LPA observation the licensee did not comply with the section cited above in that keys to medication room and prescription Thick-It left unattended and accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: Facility to self-certify on a LIC9098 that they will ensure all medications and keys to medication remain inaccessible to all those not authorized to administer medications.

Type of visit: Office

A non-compliance conference was conducted today in the Santa Rosa Regional Office to address issues concerning non--compliance . Present in the meeting were Licensing Regional Manager Carla Nuti-Martinez, Licensing Program Manager Victoria Bertozzi, and Licensing Program Analyst Christi Coppo, Licensee, Alex Varshavsky. This meeting is being conducted to discuss concerns identified by the Licensing Department regarding the operation of this facility including but not limited to: Complaint investigation that has been substantiated for not providing timely medical attention and other concerns that have been addressed in case management: visits such as reporting requirements and staff communication with licensing. - Timely Medical Attention: Facility failed to seek timely medical attention for residents in at least four [4] known cases. - Documentation: Facility did not ensure that observations of residents' condition and care are documented. - Communication with Licensing Department: Discussion around the regulatory allowance of CCL representatives to interview staff. - Medication - Facility does not currently have a Medication Technician on all shifts and is leaving PRN medication pre-poured for the NOC shift. CCL provided Administrator Qualifications and Duties and Basic Services to Licensee and provided information regarding the Technical Support Program.the state’s words, verbatim · CDSS document, Feb 4, 2026

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Christi Coppo and Ethel Contreras arrived at this facility unannounced to conduct a case management visit and was greeted by caregiver. Licensee on site but was not inside facility when LPA arrived. Licensee arrived inside facility later. LPA met with licensee Alex Varshavsky. Upon entering the facility LPA observed caregiver alone in medication room. LPA asked if licensee was here and S3 responded yes but that they did not know where he was at, he was “some place around the facility.” LPA then observed S3 to exit the med room carrying a tray of medications. LPA asked S3 if they were going to pass the medications on the tray and S3 responded yes. S3 went on to start passing the meds on their own without licensee. LPA waited for licensee in the dining room. Licensee showed up about 15 minutes later. LPA asked licensee if S3 had completed their medication training in order to pass medications on their own. Licensee responded that he was still training S3. LPA asked licensee for S3’s medication training. LPA reviewed S3’s training records. LPA observed medication test present in S3’s file. LPA observed 1 hour of “Understanding California Medication Regulations,” completed on 2/21/25. No other documentation of medication training present. (deficiency cited, see 809D). On 1/13/26 facility submitted an Incident Report (IR) for resident (R1) indicating that on 1/8/26 R1 was sent to the doctor and then the emergency room. However, IR did not indicate the nature of the event, symptoms exhibited or any cause for sending R1 to the emergency room, report did not provide description of any findings or treatment if any occurred at the hospital, or when/if R1 returned to the facility. On 1/23/26 facility submitted an IR for resident (R2) indicating that on 1/23/26 R2 was sent to the emergency room. However, Continued on 809C... Continued from 809... IR did not indicate the findings or treatment if any occurred at the hospital nor did it indicate whether or not R2 returned to the facility. On 1/23/26 facility submitted an IR for resident (R3) indicating that on 1/18/26 R3 was sent to the emergency room. However, IR did not indicate the findings or treatment if any occurred at the hospital, nor did IR indicate whether or not R3 returned to the facility. Attending physician's name not listed on any of the IRs submitted. Per regulation 87211, the facility is required to submit an IR to CCL for any incident, including but limited to, those which threaten the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. Additionally, the report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. LPA discussed Reporting Requirements regulation with licensee and importance of submitting complete reports in compliance with regulation 87211, including the findings, treatment, and disposition of the incident being reported.the state’s words, verbatim · CDSS document, Jan 27, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69 · Plan of correction due date: Jan 3, 2026

§1569.69 Employees assisting residents with self-administration of medication; training requirements (a)(1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. This requirement not met by licensee as evidenced by: Based on LPA record review, current documentation of medication training or medication shadow training not present for S3, which poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 27, 2026

Plan of correction: Facility to submit proof of completed required medication training including shadow training for S3 by plan of correction due date.

Allegation investigated: Staff did not seek medical attention to resident in a timely manner. Staff did not notify resident's PCP of change in condition.

Licensing Program Analyst (LPA) Coppo arrived unannounced to deliver findings on the above complaint allegations. LPA met with Administrative Assistant Jeralyn May. Licensee Alex Varshavsky arrived later. Complaint alleges staff did not seek medical attention to resident in a timely manner. Complainant alleges that the facility waited to provide medical attention and care to address R1’s symptoms of sweating and difficulty breathing. Complainant alleges that R1 had been experiencing symptoms of hypoxia for two [2] days before facility called EMS on 8/25/25. It was reported to complainant that facility was “waiting R1’s symptoms out” to see if R1’s symptoms would subside before they would call EMS. However, the symptoms did not subside and the facility called EMS on 8/25/25. During investigation, LPA reviewed R1’s medical records. Medical records indicate R1 was hypoxic upon arrival to hospital. During investigation, LPA reviewed R1’s medical records. Medical records indicate R1 was hypoxic upon arrival at the hospital. During investigation, LPA reviewed chart notes for R1. Review of chart notes show that Continued on 9099C... Substantiated Continued from 9099... staff noted on 8/24/25 that “R1 continues to have a fever” and was given PRN Tylenol. Per regulation 87465(c)(3), a record of each PRN dose is to be maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. LPA requested the PRN MAR for R1 from the licensee, but licensee could not provide any PRN MAR for R1, instead licensee provided a MAR for prescription medications. However, MAR provided did not reflect the information required per regulation 87465(c )(3). Therefore, the facility could not show documentation that R1 was administered any medication on the day of 8/24/25 to address their fever and did not document R1’s outcome of receiving the medication, or if they ever actually received it. Complaint alleges staff did not notify resident's PCP of change in condition. During investigation, facility provided LPA with proof of faxed notification to R1’s primary care physician (PCP) dated 8/31/25. However, staff (S2) advised LPA that R1’s PCP never responded to any of S2's faxed requests. S2 said they called and got clarification as to why all the requests were being ignored or not answered. S2 explained to LPA that they were advised by staff at PCP office that fax is not the best way to communicate and may result in communication not being acknowledged or received. During investigation, LPA reviewed written evidence showing that S2 acknowledged that communication via fax to R1's PCP was not the best way to communicate. S2 acknowledges that they were advised as such from the PCP on subsequent faxes they sent to R1’s PCP. However, S2 continued to send requests to the PCP via fax as evidenced by faxes sent on 6/2/25, 6/8/25, 8/24/25, and 8/25/25. So, although facility had previously been advised that fax is not the best way to communicate they continued to communicate only through fax. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 21-AS-20251006185042

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 19, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...for the provision of adequate services. This requirement not met by licensee as evidenced by: Based on LPA record review and interview, the licensee did not comply with the section cited above in that facility could not show that R1 received timely medical attention, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: Facility to conduct in-service training on personal rights and providing timely medical care. Facility to submit plan to conduct training by plan of correction due date. Training to be completed no later than 1/5/25. Training logs submitted to show trainer, attendees, date, subject matter and duration.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(d) · Plan of correction due date: Dec 31, 2025

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration provided all of the following requirements are met...This requirement not met by licensee as evidenced by: Based on LPA record review and interview, the licensee did not comply with the section cited above in that facility does not use PRN MARs for documenting the administration of PRN medication, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: Facility to conduct an one hour duration of in- service training for all staff on medication management by plan of correction due date. Training logs submitted to show trainer, attendees, date, subject matter and duration.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Dec 31, 2025

87211 Reporting Requirements (a) Each licensee shall furnish... (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This requirement not met by licensee as evidenced by: Based on LPA record review and interview, the licensee did not comply with the section cited above in that facility could not show that facility did not notify R1's PCP via a method of communication shown to be received which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: Faciliy to self-certify on a LIC9098 that they will maintain compiance with all reporting requierments as outlined in regualtion 87211

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Coppo arrived unannounced to conduct this Case Management Visit to follow up on incident reports and a death reported received by the facility. LPA met with Administrative assistant Jeralyn May. Licensee Alex Varshavsky arrived later. On 10/19/25 facility submitted an Incident Report for resident R2 indicating that on 10/17/25 R2 was found in their room shaking. Emergency Medical Services (EMS) were called and R2 was taken to the hospital. R2 was seen for a new seizure like activity, dehydration, and a urinary tract infection (UTI). A follow-up appointment was scheduled for 12/2/25. On 10/30/25 the facility submitted an Incident Report for R2 indicating that on 10/29/25 R2 was observed to have a dark colored urine, presenting as weaker than baseline, and seemed more confused than baseline. The facility called EMS and R2 was taken to the hospital. On 11/10/25 facility submitted a Death Report for R2 stating the date of death as 11/2/25 with the immediate cause listed as cardiopulmonary arrest. Conditions prior to or contributing to death were listed as septic shock due to urosepsis/UTI with underlying cause: acute metabolic encephalopathy. On 12/8/25 facility provided R2's Death Certificate to CCL for review. Review of Death Certificate shows causes of death and underlying causes to be the same as facility listed on death report submitted: immediate cause listed as cardiopulmonary arrest. Conditions prior to or contributing to death were listed as septic shock due to urosepsis/UTI with underlying cause: acute metabolic encephalopathy. During case management visit, LPA reviewed chart notes and conducted interviews. Per R2's chart notes on Continued on 809C... Continued form 809... 10/23/25 and 10/24/25 R2 experienced falls. No chart notes found in relation to symptoms R2 was experiencing on the days before or after R2's visit to the hospital on 10/17/25. One chart note mentions that R2 went to the hospital because they were "not looking well" and that their eyes would roll back and looked like R2 was having a seizure. Notes indicate that the hospital called and said R2 had a UTI. However, there are no initials for chart note entry and no date listed. LPA also reviewed R2's discharge papers from their hospital visit on 10/17/25. Discharge papers indicate diagnosis of UTI and reason for the visit listed as seizure. LPA review of R2's physician's report dated 7/24/25 shows R2 has a history of UTIs. Review of facility communication with R2's doctor shows they notified the doctor 3 separate times on 10/19/25 indicating that R2 was on antibiotics, having trouble with bowel movements, and not able to hold their medications in their hand without dropping them and having difficulty swallowing them. An order for crushed medications and Miralax were requested. During case management visit LPA conducted interviews. Interviews did not provide any clarifying information. It is not clear when R2 began exhibiting a change of condition. LPA spoke to licensee about the importance of clear, accurate, and thorough documentation and charting notes. On 11/25/25 facility submitted an Incident Report for resident R3 indicating that for several weeks R3's toe had been progressively darkening in color. Facility notified R3's primary care physician (PCP), R3 was prescribed antibiotics and was scheduled for a podiatry appointment on 11/25/25. On 11/20/25 facility noticed that R3's toe seemed to be getting worse. Facility reports to have sent an updated request to her PCP but reports they did not receive a response. On 11/23/25 the discoloration of R3's toe had further deteriorated. Due to R3's decline facility requested a professional non-emergency evaluation. After EMS performed an evaluation R3 was transported to the hospital for assessment. R3 is currently back at the facility. During case management visit, LPA reviewed R3's chart notes and conducted interviews. Interviews yielded conflicting dates of care and notification to R3's doctor. However, chart note shows that on 9/29/25 R3 was Continued on 809C(2)... Continued from 809C... experiencing a lot of pain, their leg was swollen and purple, and they could not stand on their leg at all the entire day. One other chart note indicated that R3 complained of pain in their left leg but the date of the chart note is illegible. Interview conducted reports that R3 was exhibiting the same swollen purple leg for at least one week. During case management visit, LPA reviewed R3's After Visit summary which indicated that R3 was seen for cellulitis and was prescribed antibiotics for 10 days and diagnosed with a primary diagnosis of a pressure ulcer of the left toe deemed unstageable, the ulcer was covered by slough and/or eschar and an ulcer of the right toe with unspecified depth; cellulitis. R3 is now on hospice. During case management visit, LPA reviewed facility communication with R3's doctor. On 11/12/25 facility faxed R3's doctor informing them that R3's toe looks about the same and that they have bright red cellulitis with watery drainage and the toe nail looks as if it is going to fall off. Additionally, the facility advised the doctor they had been covering it with a small amount of antibiotic ointment and a non-stick bandage. On 11/13/25 the doctor responded advising to continue with care facility had previously described and instructed facility to make a podiatry appointment for R3. An appointment was scheduled for 11/25/25. On 11/20/25 facility faxed doctor indicating R3 had completed the round of antibiotics prescribed on 11/6/25 but was not improving; in fact, they wrote, the condition is worsening. Per licensee, the doctor did not respond. On 11/23/25 at 5:50pm licensee faxed R3's doctor urgently requesting advise on the next steps to be taken for R3 since R3 was still showing no signs of improvement and was worried about the possibility of tissue necrosis or some other serious underlying condition. A deficiency of regulation 87411(a) is being cited today as facility did not seek timely medical care as evidenced by having a purple and swollen leg since at least 9/29/25 but was not seen by a doctor until 11/6/25 (deficiency cited, see 809D). Additionally, During a complaint investigation, Licensing Program Analysts (LPAs) Cuadra and Coppo attempted to conduct interviews with staff to inquire about the timely medical care of a resident. As a result, Continued on 809C(3)... Continued from 809C(2)... on 11/13/25, licensee Alex Varshavsky sent an email to CCL advising that he has instructed his staff not to discuss any resident information with external callers, to refer all inquires immediately to the Administrator or facility office, and to report any unusual or suspicious calls. On the same day, Licensing Program Manager (LPM) Bethany Moellers responded to the licensee and advised that “the department has jurisdiction to contact the staff directly during complaint investigations and/or other matters which does not require being filtered through facility administration. This [instruction] appears to be placing a divide between your staff and the department.” The licensee then responded to LPM that he has now revised his instruction to his staff to be, “we want to remind you to be cautious about calls from anyone asking for information about our residents. If you receive such a call, please ask the caller to contact the facility directly with any questions, and then politely end the conversation. We do not share your phone numbers or allow anyone to call you about residents. The licensee went on to further instruct his staff: We want to remind everyone to be cautious when receiving unexpected calls, especially those asking about our residents or facility operations. Licensing Program Analysts (LPAs) and the Department do at times contact staff directly as part of official investigations. However, because fraudulent calls are increasingly common, it is important that any unexpected caller be verified before you share any information or continue the conversation. If someone calls and identifies themselves as being from the Department, it is completely appropriate - and encouraged - to request verification. You may politely ask the caller to send a confirmation email to you or to the facility office before proceeding.” Subsequently, on 11/19/25, LPA Coppo attempted to interview staff. During investigation, it was reported to LPA that staff S1 had first-hand knowledge of R1’s condition of health before facility called EMS; however, S1 reported to LPA “that people from the state don't usually call employees asking about residents. S1 explained that this recently was talked about from the owners and they told everyone to have CCL contact the owners with any questions we had.” So, LPA was not able to conduct interview with staff. During this visit, LPA discussed the importance of confidential interviews as part of an investigation and while facility staff should not provide protected information regarding residents to individuals, they are able to provide information to CCL staff. LPA provided regulation 87755 Inspection Authority of the Licensing Agency Continued on 809C(4).... Continued from 809C(3)... which states in part, “The licensee shall ensure that provisions are made for private interviews with any resident or any staff member; and for the examination of all records relating to the operation of the facility” and Health and Safety Code 1569.37 Whistle blowers; retaliation. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, Dec 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 19, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...for the provision of adequate services. This requirement not met by licensee as evidenced by: Based on LPA record review and interview, the licensee did not comply with the section cited above in that R3 did not receive timely medical care, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: Facility to conduct in-service training on personal rights and providing timely medical care. Facility to submit plan to conduct training by plan of correction due date. Training to be completed no later than 1/5/26. Training logs submitted to show trainer, attendees, date, subject matter and duration.

Allegation investigated: -Staff did not assist resident with obtaining medical care in a timely manner. -Staff did not report incident to appropriate parties.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to delivered findings regarding the allegations listed above and met with Administrative Assistant, Lisa DiBartolo. There is an allegation regarding staff did not assist resident with obtaining medical care in a timely manner. According to the reporting party, on 8/25/2025 at 1AM, the emergency medical responders (EMS) were called to the facility regarding a resident (R1) needing care. Upon arrival, the EMS team assessed R1 and observed that the resident needed immediate care regarding a respiratory condition, when staff (unknown name) reported that R1 had been in that state of condition for two days, but R1 had not received medical care for two days and the staff could not provide a reason, then R1 was transported to Sutter Hospital Emergency Room for care and it was unknown if the resident was admitted into the hospital. Based on records review, on 8/24/25 a fax was sent to R1’s primary physician advising that R1 was showing signs of being ill, had a temperature of 99.1 degrees, that staff provided R1 with acetaminophen (1,500 mg tablet), and that the party responsible was notified along with a fax confirmation sheet dated 8/24/25 at 10:53:10am been successfully sent to fax # 18008668844. Continue in LIC9099C... Unsubstantiated Continued from LIC9099... A second fax was successfully sent to R1’s primary physician on 8/25/25 at 2:05:29pm advising that R1 was in their bed showing signs of sweating, trouble breathing and notifying them of R1’s transportation to Sutter hospital. LPA obtained police records #SD250826005 confirmed information above mentioned regarding staff seeking medical care for R1 with an unfounded resolution. Also, LPA reviewed incident reports submitted to the department, where it was confirmed that the facility submitted an incident report on 8/25/25 regarding R1’s condition. Based on LPA’s observations, records review and interviews conducted with pertinent parties, it was determined that the facility has followed proper protocol regarding seeking timely medical care assistance to R1 and it’s unclear the reasons why the unknown staff told the reporting party that R1 had not received medical care for two days. A finding that the complaint allegation of staff did not assist residents with obtaining medical care in a timely manner is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Another allegation of staff did not report the incident to appropriate parties. Per Reporting Party, R1 was transported to the hospital, after they allegedly needed immediate care due to respiratory condition. According to the Reporting Party, unknown staff told them that they had not notified R1's responsible party of their condition. Based on records review, R1’s identification and emergency information form (LIC601) revealed that R1 has listed placement agency and nearest relative person as their responsible parties, which coincides with R1’s physician orders for life-sustaining treatment (POLST) form. Based on LPA’s observations, records review and interviews conducted with pertinent parties it was confirmed that the facility have reported the incident to one out of the two R1’s party responsible listed on file, the findings coincide with police records #SD250826005 obtained, where the case was determined as unfounded after police officers have conducted confidential interviews with pertinent parties. A finding that the complaint allegation of staff did not report the incident to appropriate parties is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Sep 23, 2025 · control 21-AS-20250826101958

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct this Case Management Visit to follow up on a self-death report dated 7/21/25. LPA met with Administrative Assistant, Lisa DiBartolo. Per death report, on 7/19/25 at 12:37pm, resident (R1) was in the dining room having lunch and showed signs of chocking, staff called 911 immediately, who performed required treatment, but they were unsuccessful and R1 was declared deceased at 12:43pm. Responsible parties were notified. Upon the department was notified, LPA requested death certificate for review due to R1 was not receiving hospice services and pending investigation status was observed in the certificate. On 9/16/25, Licensee submitted death certificate dated 9/11/25 indicating that R1 chocked on a piece of hamburger, which resulted in them passing away while under the care of the facility. During today's visit, LPA reviewed R1's physician report dated 5/20/25 and care plan dated 5/13/25 including any doctor's order involving special diet, food restrictions or assistance needed regarding feeding the resident, which were not instructed by the doctor as needed. R1 was needing constant supervision due to disruptive behavior towards others, which it was related to their diagnosis. Also, LPA confirmed that the call alert system was working properly, and LIC500 Personnel Report indicates that there was staff present during the incident who got alerted, and timely contacted the medical emergency responders to assist resident in the facility. LPA conducted interviews with staff (S1 and S2) who confirmed above information. Based on records review and interviews conducted with staff it appears like the facility followed up adequate protocol including timely medical assistance for resident. No deficiencies cited during today's visit. Exit interview was conducted with Administrative Assistant and a copy of this report was given.the state’s words, verbatim · CDSS document, Sep 23, 2025

Allegation investigated: -Facility staff are unlawfully confining resident to room. -Facility staff are not adhering to resident care plan. -Facility staff are not providing resident with oral hygiene.

Licensing Program Analyst (LPA) Marisol Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Lisa DiBartolo, Administrative Assistant. Licensee, Alex Varshavsky was unable to come to the facility and was available via phone. The Department received an allegation of facility staff are unlawfully confining residents to rooms. Per Reporting Party, on July 24, 2025, at approximately 10:30 AM, staff at an adult day program reported that a client tested positive for COVID-19. The facility subsequently tested all clients and sent them home. On July 25, 2025, residents (R1) disclosed that they were being locked in their room due to been positive for COVID-19 test results, regardless of R1 tested negative. Continue on LIC9099C... Unsubstantiated Continued from LIC9099... Based on interviews conducted with facility Administrative Assistant it was determined that the facility was notified that R1 was exposed to a person who had a positive test result for Covid19, then it was instructed by the Licensee to contact R1’s day program to obtain additional information and after three unsuccessful contacts, so the licensee advise staff to follow their facility protocol to isolate R1 in their room until it was clear if R1 was positive or not to ensure the health and safety of the residents in care, R1 was isolated in their room for three days as stated in their facility protocol as follow: “there shall be separation and care of residents whose illness requires separation, including quarantine or isolation, from others”. LPA was unable to find any supporting evidence that staff could or not have unlawfully confined R1 to their room due to contradictory information which it was not clear if resident was isolated or confined to their room due to Covid19 exposure. However, based on records review of facility daily care notes for the month of July, R1 was assisted with activities of daily living. A finding that the complaint allegation occurs of facility staff are unlawfully confining residents to rooms is unsubstantiated meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Another allegation of facility staff is not adhering to resident care plans. According to the reporting party, R1 has a care plan that includes 1:1 supervision due to their high fall risk and dementia diagnosis, but on July 28, 2025, at around 9:10 AM, R1 was observed alone in their room without supervision. However, based on interviews conducted by LPA with the complainant it was revealed that they were under the impression that R1’s care plan included 1:1 supervision due to their diagnosis of dementia and higher fall risk, but there was no supporting evidence of such information in their agreement between the facility and R1’s responsible party. LPA obtained written communication between the facility and R1’s responsible party dated July 24, 2025, at 4:38pm regarding upcoming monthly payment increase effective August 1, 2025, due to significant increase of level of care to meet R1’s evolving needs including constant supervision due to high fall risk, two-person assistance for all transfers, wheelchair for mobility, total assistance with feeding (pureed diet), total assistance with toileting, showers, dressing, and personal hygiene, full medication management. Continued on LIC9099C... Continued from LIC9099C... Based on records, a review of R1’s care plan dated 7/2/25 confirmed above information detailing the need for an increase in supervision due to the high risk of falls through routine safety checks to be done. A finding that the complaint allegation occurs of facility staff is not adhering to resident care plans is unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding the allegation of facility staff are not providing residents with oral hygiene. The Reporting Party mentioned that R1 is not receiving assistance with oral care, such as brushing their teeth or flossing. It was reported by an outside party individual (I1) that R1 was observed regularly with a buildup of old food between their teeth. Based on interviews conducted with I1, who stated that due to the frequent occurrence of the incidents, they have not consistently documented when R1 has been observed with oral residue/leftover food in their mouth, but remarked that since R1 moved into Mirabel Lodge the lack of oral care has been a problem, which it has been discussed with Mirabel staff and administrative assistant who reminded the facility twice about R1’s physician order for "oral care after meals". Based on records review, R1’s physician report dated 7/21/25 confirms the above information. However, R1’s care notes for the month of July 2025 revealed some gaps mainly in the morning shift in R1’s oral hygiene as not been performed. Although, administrative assistant stated that the gaps found in the oral hygiene care notes were due to staff forgot to enter their initials in the log. Also, LPA conducted interviews with staff (S1, S2 & S3) who confirmed that the facility has a rotating schedule, and they indicated that they will assist R1 with oral hygiene when it was in their assigned group, but at times they will forget to fill in the care notes because they got busy with other duties assigned. A finding that the complaint allegation occurs of facility staff are not providing resident with oral hygiene is unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Sep 2, 2025 · control 21-AS-20250728132515

Allegation investigated: -Personal Rights. -Facility staff did not follow physician care orders.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and was greeted by staff Teresa Astudillo. Licensee Alex Varshavsky and Administrative Assistant, Lisa Dibartolo via phone who gave authorization to staff to sign the report. The Department received an allegation of personal rights. Per Reporting Party, on 6/27/25, resident (R1) was observed to be assisted by staff (S1) who entered the room and made an inappropriate comment to R1, when S1 was about to use prescribed gait belt remarked in Spanish “Oh, ya es hora de amarrarle? which translates to: “Oh, is it time to tie them up?”. Approximately 25 minutes later, R1 requested assistance to another staff member (S2) to get out of bed, S2 entered the room and without announcing their intentions proceeded to pulled R1’s legs, S2 did not acknowledge R1’s request to wait, lifted them by their affected arm, stood them upright, used their legs to push R1’s lower limbs toward a wheelchair and ignored once again R1’s grunted in discomfort as they were placed into the wheelchair. S2 left the room without any further comment or assessment to ensure that R1 was fine. Continue on LIC9099C... Substantiated Continued from LIC9099... On 7/9/25, LPA conducted a 10-day visit to the facility, made observations, obtained pertinent records and conducted interviews with staff. During the visit, LPA requested S1 to demonstrate how do staff were trained to properly transfer a resident who needs two-person assistance. S1 reached out to another staff (S2) and told them in Spanish "ayudame con esta", which translates to "help me with this" not referring to resident's name. Once S2 came to the resident’s room, both caregivers initiated the transfer without communicating their intentions to the resident. Upon LPA’s inquiry about both staff not communicating with R2 their intention of transferring R2 from their wheelchair to their bed, their response was that R2 was non-verbal, but they stated that R2 could hear us perfectly. However, they never communicate with R2. Based on staff training records for both caregivers it indicates that staff have received personal rights training, including the dignity of residents and personal care with residents’ transfers within the last year. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Another allegation of facility staff did not follow physician care orders. The Reporting party stated that on 6/27/25, R1 was observed to be transferred using one-person assist by staff (S1), S1 lifted R1 by their upper extremity, which R1 has repeatedly identified as a source of pain. Despite doctor’s order to use a gait belt, S1 continue to use extremity during transfers, these instructions do not appear to have been followed. On 7/9/25, During the visit, LPA requested S1 to demonstrate how do staff were trained to properly transfer a resident who needs two-person assistance. S1 selected resident (R2) who was in the common area in their wheelchair with other residents watching tv. S1 initiated pushing R2's wheelchair towards their bedroom without notifying R2 of the reasons why they were been transferred to their room, then S1 reached out to another staff (S2) to help with transfer. Once S2 came to R2’s room, both caregivers initiated the transfer without communicating their intentions to the resident, wheelchair was not positioned near nor parallel to the bed, both lifted the resident from their wheelchair and threw them to the bed by pushing their legs with their foot and not even holding their head to prevent them from possibly hitting the wall. Continue on LIC9099C... Continued from LIC9099C... After the demonstration was complete, LPA inquired if they ever use a gait belt for transfers and they replied to no. According to both staff (S1 & S2), neither of them use gait belts nor use the hoyer-lift machine because they don't like it. Based on records review, LPA was provided with a list of residents in care and two assignment sheets dated 7/3/25 with a total of six residents (R2, R3, R4, R5, R6 & R7) that need two-person assistance. Staff training records for both caregivers revealed that staff have received transfer training techniques within the last year. LPA requested the facility’s transfer protocol as well as gait belt procedures, but the Administrative Assistant stated that they don't have one, but they started drafting one to train staff as soon as possible. LPA reviewed R1’s file, which revealed some contradictory information between the register of facility residents (LIC9020 dated 7/1/25 where it describes R1 as ambulatory status. However, the records review of the incident report dated 6/2/25 indicates that on 5/27/25 R1 was found on the floor in their room, after them attempting to transfer themselves from bed to wheelchair and fall. According to the administrative assistant, R1 walks while on a day program, but it is very unsafe when they use their walker, so they need a wheelchair. Although, their physician report (LIC602) needs to be updated to reflect the ambulatory status change. According to R1’s care plan dated 9/29/24, there is an order for a wheelchair as of 7/25/24, their emergency book from placement agency dated 4/11/25 confirmed the use of gait belt needed as an assistive device which needs to be used to help safely transfer or assist with sitting/standing to R1. Furthermore, there is a doctor's order dated 12/20/24 that confirms "daily use of gait belt, walker for home exercise program to tolerance”. However, R1’s care notes about assistance do not indicate the use of gait belt for R1 as prescribed by their doctor. Per administrative assistant, the gait belt is not necessary for R1 because they are able to stand and sit without it. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. **Civil Penalty assessed in total amount of $250.00 for repeated violation within 12 months. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with the Administrative Assistant. Exit interview conducted with the Administrative Assistant via phone and copy of this report was given.the state’s words, verbatim · CDSS document, Aug 1, 2025 · control 21-AS-20250630160009

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(1) · Plan of correction due date: Aug 2, 2025

Type A - §1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other people. This requirement has not been met as evidence by: Based on LPA’s observations and interviews with staff, the facility staff assisted residents in care using inappropriate comments and not notifying the residents of their intentions when performing transfers, which poses an immediate risk to the health and safety of clients in care.the state’s words, verbatim · CDSS document, Aug 1, 2025

Plan of correction: The facility will conduct all staff training regarding personal rights. Training subject, date of training and signed attendance forms to be submitted to CCL by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Aug 2, 2025

Type A - 87465 (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication...the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on records review and interviews with staff, there is a written order from a physician dated 12/20/24 indicating the need for gait belt shall be utilized daily to assist R1 with transfers, but staff (S1 & S2) interviews revealed that they do not use gait belts with none of residents in care, which poses an immediate risk to the health and safety of clients in carethe state’s words, verbatim · CDSS document, Aug 1, 2025

Plan of correction: The facility will conduct all staff training regarding use of assistive devices & postural support management. Training subject, date of training and signed attendance forms to be submitted to CCL by POC due date. **Civil Penalty assessed in total amount of $250.00 for repeated violation within 12 months.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct this Case Management Visit to follow up on two self-incident report dated 5/12/25 and 6/2/25. LPA met with Teresa Astudillo (Med-Technician). Licensee Alex Varshavsky was not able to come to the facility, but were available by phone and gave authorization to staff to sign the report. Per incident report, on 5/8/24 resident (R1) was observed limping and their left leg appeared swelling, staff notified their physician who instructed them to send R1 to the hospital for further evaluation, where they were diagnosed with mildly displaced patellar fracture with history of osteoporosis. R1 returned to the facility same day. Second incident report, On 5/27/25 resident (R2) was found on the floor, after attempting to transfer themselves from bed to the wheelchair. According to incident report, R2 did not call for assistance. Staff immediately called paramedics who assessed the fall, R2 was transported to the hospital for further evaluation, where they were treated for bone bruising and abrasions. Both responsible parties were notified. During today's visit, LPA have reviewed R1's & R2's physician report and care plans. After this incident, the facility have developed a plan of action including implementation of person centered care to meet their care needs. Also, LPA confirmed that the call alert system was working properly, which it has been an area of concern previously discussed with the Licensee. After pulling the call button for help, LPA heard a sound beep in the office and staff was alerted, who arrived timely to assist resident in the room. LPA observed paper products available in bathrooms used by residents including toilet paper and paper towels. No deficiencies cited during today's visit. Exit interview was conducted with Med-Tech and a copy of this report was given.the state’s words, verbatim · CDSS document, Jun 5, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marisol Cuadra arrived unannounced to conduct a Case Management -Other and met with Administrative Assistant, Lisa DiBartolo. The purpose of this case management is to update Fire Clearance received on 3/27/25. The Facility received an approved fire clearance dated March 27, 2025 that allows for 34 non-ambulatory residents and 7 bedridden might be bedridden rooms as follow: room #1 as single bedroom and room #10, 19, and 20 shared resident bedrooms. However, LPA have noticed that previous fire clearance dated September 26, 2024 was approved to have a secured perimeter. During today's visit, LPA requested a revised fire clearance indicating the approval of secured perimeter for this facility to generate an updated license reflecting revised items. The facility obtained updated fire clearance including areas of concern were addressed. LPA will update the system and will send an updated license reflecting the changes. No deficiencies cited during today's visit. Exit interview conducted with Administrative Assistant and copy was given.the state’s words, verbatim · CDSS document, Apr 2, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Contreras and Cuadra arrived unannounced to conduct the required 1-year annual inspection. LPAs met with Lisa DiBartolo, Administrative Assistant. The facility has residents receiving hospice services and residents with Dementia diagnoses. Annual fees are current. Required postings were observed. Contact information was reviewed. Upon arrival, LPAs/staff noticed one gallon of detergent and 11 bottles of cleansers sitting on reception area accessible to residents. There were three staff around the reception area (technical advisory issued). LPAs/staff toured the facility inside and outside at approximate 9:30am: Facility has a centralized fire alarm system that is maintained by a vendor and inspected by the local fire department. Facility's last maintenance was conducted 12/19/24. Facility has a locked perimeter. Smoke detectors, sprinklers, carbon monoxide detectors were present throughout the facility. Fire panel was last inspected 12/19/2024. Last disaster drill was conducted on February 2025. The facility is a one story building and has an approved fire clearance dated September 26, 2024 that allows for 34 ambulatory and 28 non-ambulatory residents and no bedridden resident. However, during records review two (R1 and R2) out nine residents have a bedridden status and are occupying room #1 (R1) and room #19 (R2), which are not cleared by the Fire Department as bedridden rooms. Licensee is operating outside the limitation of the license by accepting a bedridden resident in a non-ambulatory room. LPA/staff discussed the issue with R1 and R2 to provide the option to submit a request to the Fire Marshall to assess bedrooms to grant fire clearance. According to the Administrative Assistant, R1 and R2 are not bedridden and they have reached out during LPAs vitis to both physicians to obtain an updated physician's report (LIC602). During the visit, LPA spoke with R1 and R2 who expressed that they are not fully bedridden and they are in agreement to obtain an updated medical assessment. Fire Extinguishers were last serviced February 2024. As a result of the fire clearance violation, an immediate civil penalty in the amount of $500 is issued today. Continue on LIC809C... Continued from LIC809... At approximate 9:45am LPAs pulled emergency alerts in resident's room (#5) and staff did not respond in a timely manner. According to Administrative Assistant, it appeared that the system was not on, so it did not alert staff to respond to call alerts. However, after the system was on, LPAs pulled the call alerts again and staff responded timely. At approximate 9:50am LPAs/staff observed auditory alarms in room #7 and #4 resident bedrooms sliding glass door exits were not activated (technical violation issued). At approximate 10:00am LPAs/staff observed bathroom toilet in room 7 found cracked and staff placed out of order sign, sticky floor observed throughout facility and trash can with no lid was observed in bathroom room 20, Bathroom in room 12 observed with feces on floor in shared bathroom. Chairs in some resident's bedrooms were not available. At approximate 10:05 am LPAs/staff observed unpacked dry goods with no expiration dates noted. Also, LPAs observed that residents were being served hot dogs, mashed potatoes and salad for lunch. LPAs held a conversation with staff regarding the importance to serve residents with nutritious food. At approximate 10:10am LPAs/staff did not observed toilet paper and paper towels available to resident's in shared bathrooms. Facility had sufficient perishable and non-perishable food. LPAs initiated file review at 11:00am. Nine residents and five staff files were reviewed. Residents have their care plan and medical assessments updated. Staff do have annual required training hours completed and at least one staff per shift have current CPR. During file review, LIC500 revealed that 2 out of 27 staff were cleared, but they were not associated to facility; LPA informed staff that the staff should never be working and providing care to residents prior to a criminal record clearance or exemption. Civil penalties are being assessed in the amount of $500 for allowing a person to work, reside or volunteer in the facility without a been associated to the facility. Administrator certificate for administrator Alex Varshavsky 7019479740 expires 7/15/26. At approximately 12:30pm a spot check of medications were conducted and 2 out 5 residents (R2 and R3) medications were not given to residents according to their physician's order. Licensee to submit updates of the following documents by 3/27/25: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), control of property and Liability Insurance. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Administrative assistant who was informed that the Department will be reviewing if further action is needed to address the overall compliance of the facility and a copy of this report was given.the state’s words, verbatim · CDSS document, Mar 13, 2025

The state marks this report as 9 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: -Staff did not dispense medication to resident as prescribed.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegation and met with Administrative Assistant Lisa DiBartolo. Regarding allegation of staff did not dispense medication to resident as prescribed. Per Reporting Party, R1 had prescription orders for scheduled doses of Morphine and Haldol, but administrative assistant refused to provide R1 with these medications unless R1 can ask for them. Also, on 04/22/2024, administrative assistant staff refused to give R1 their morning dose of Seroquel, which they were supposed to receive twice per day at no set time. Upon noticed of the missing dose, the reporting party approached administrative assistant, but they were told that R1 was asleep when they passed the rounds of medications for that morning and they refused to give it to R1 once they woke up, even though hospice advised administrative assistant to assist R1 with the medication. Continues on LIC9099C... Substantiated Continued from LIC9099... There were other incidents where the reporting party have observed frequently crushed R1’s time released Metoprolol, which could have killed R1. Per reporting party, staff was also observed R1 chewing extra-strength Tylenol after it was dispensed to resident. Based on interviews conducted with outside party, it was revealed that an outside agency was concerned regarding medications were properly given to R1 as prescribed by their doctor. LPA obtained hospice records confirming concerns regarding medication administration. Regarding crushing medication incidents, hospice records confirmed that as of 4/7/24, R1 received a physician’s verbal order to crush medications and on 4/10/24, R1’s physician followed up with a written doctor’s order allowing facility staff to crush medications and give with small amount of food or on a teaspoon. On 4/22/24 at 5:36pm, hospice records revealed that R1 did not receive their morning dosage of Seroquel, the hospice nurse spoke with staff who stated that R1 is on schedule to have Seroquel 150mg at 8am and 5pm, so they could not give it late, the facility will need the order to be changed and its medication was not given. Hospice nurse explained staff that the order indicates twice daily, but staff created dosing schedule. Order obtained supports twice daily with no time indicate. Therefore, facility staff did not dispense medication to resident as prescribed per doctor’s order. Based on facility records of Medication Administration Records dated 4/22/24 confirmed that Seroquel medication was not given to resident. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given. **Immediate Civil Penalty assessed in the amount of $250 for repeated violation within 12 months. Continued from LIC9099A... However, according to R1’s responsible party, they were not notified by the facility staff about the change of ambulatory status noticed on 3/30/24. The responsible party indicated that on 3/24/24, R1 was not observed needing to use a wheelchair to ambulate and the administrative assistant was refusing that R1 received hospice services, because they did not consider that R1 was dying. Although, R1’s physician report dated 2/6/24 indicates that R1 have a non-ambulatory status including dependency of mechanicals aids such as walkers and wheelchairs. On 4/2/24, the Department received an incident report informing that on 3/30/24 at 9pm, R1 was not doing well, facility staff contacted emergency medical responders (EMS) who assessed R1 and spoke with their responsible party who did not want R1 to go to the hospital, R1 did not go to the hospital, their responsible party notified R1’s physician and referral for hospice services was given. Hospice records revealed that on 3/30/24 staff stated that R1 has been ambulating independently. However, R1’s responsible party differs stating that R1 has been needing to a wheelchair occasionally for past few weeks. Hospice nurse observed R1 getting up independently and walk back to their room when hospice chaplain was visiting that afternoon. Hospice records indicated that on 4/1/24, R1 was observed ambulating independently through the facility. On 4/17/24, R1 was observed walking around the facility holding onto caregiver’s hand. Although, it is unclear to determine whether the facility staff have informed R1’s responsible party about both incidents. It was revealed that R1’s responsible party were aware of R1’s rapid health declining since 2020 due to progressive cognitive primarily in memory and executive function more than visuospatial. During interviews conducted with R1’s responsible party on 8/8/24 such information was also confirmed. A finding that the complaint allegation of staff did not inform resident's authorized representative of a change in resident's condition is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 21-AS-20240724140551

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Aug 30, 2024

Type A- 87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. Based on interviews with staff and records review Licensee did not ensure proper management of medication by staff did not give R1’s their dosage of Seroquel 150mg as prescribed by their physician’s, which poses an immediate risk to the health & safety of residents in care.the state’s words, verbatim · CDSS document, Aug 29, 2024

Plan of correction: Licensee agrees to retrain staff on medication management from an outside vendor & will write a plan to ensure resident medications will be dispensed to residents in care as prescribed by their physician daily. Licensee to submit the updated plan to CCL by POC due date to clear the citation. **Immediate Civil Penalty assessed in the amount of $250.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct this Case Management Visit to follow up on an incident report dated 7/13/24 and SOC341 dated 7/15/24. LPA met with Lisa DiBartolo (Administrative Assistant). Per incident report, on 7/13/24 resident (R1) approximately at 4:15pm went in another resident's (R2) room, staff redirected R1 to leave the room, but R1 was aggressive and hit R2 twice on their back and attempted to hit staff. Facility staff called 911 and EMTs determined that R1 needed further assessment at the hospital. Per discharge documents provided by the facility, R1 was seen for altered mental status and discharged with a diagnosis of hypernatremia, which is an electrolyte disorder. There were no new or change of medications order. Responsible parties were notified. During today's visit, LPA have reviewed R1's physician report dated 3/12/24, who has a diagnosis of Dementia. After this incident, the facility have developed a plan of action including assessment of R1's behavior, communication and engagement of their responsible parties along with facility staff, implemented person-centered care to meet R1's needs, provide additional staff training including managing techniques, perform continuous evaluation of the effectiveness of implemented strategies. LPA was also provided with written request submitted by the facility to R1's physician dated 7/10/24 at 4:59pm, 7/11/24 at 1:12pm and 7/15/24 at 9:33am requesting medication review and possible adjustment to address R1's aggressive behavior without receiving any response from their physician as of today yet. LPA will review documentation received to determine if further action is needed. No deficiencies cited during today's visit. Exit interview was conducted with Administrative Assistant and a copy of this report was given.the state’s words, verbatim · CDSS document, Jul 16, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct this Case Management Visit to amend a report originally dated 05/23/2024. LPA met with Lisa DiBartolo (Administrative Assistant) The document requires amending because secured perimeter was not reviewed by the Department on error when there was a change of ownership. The licensee have submitted pertinent documentation for the Department to review. The Fire Department is engaged and approval is pending. Currently, the facility is operating under fire clearance approved on 11/16/22 without secured perimeter waiver. Report was amended and signed today, 7/9/2024. No citations were issued during this visit.the state’s words, verbatim · CDSS document, Jul 9, 2024

Allegation investigated: -Personal Rights.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegation and met with Administrative Assistant, Lisa DiBartolo. The Department received an allegation of Personal Rights. On 4/5/24 resident (R1) told reporting party that another resident (R2) enters their room during the night, punches and stabs them in the stomach. Based on records review, LPA obtained Sonoma County Sheriff’s office report #SD240960118 indicated that on 4/5/24 from the reporting party stating that R1 stated that they had been abused at the facility by another resident (R2). However, there were no injuries consistent with their statement resulting in an unfounded case disposition. The Department have received incident reports dated 3/22/24, 3/31/24, 4/2/24, 4/11/24, 4/19/24, 4/24/24, 4/28/24 and 4/30/24 regarding R1’s behaviors including verbal attempts to commit suicide and medical emergencies due to R1 keeps pulling their catheter out several times. Continues on LIC9099C... Unsubstantiated Continued from LIC9099... R1’s physician report dated 8/14/2023 revealed that they have a primary diagnosis of delusional cognitive disorder, which it was confirmed with R1’s discharge documents provided that do not indicate any skin condition when assessment was performed during R1’s hospitalization. During LPA’s visit to the facility on 5/2/24, LPA toured the facility, it was observed that R1’s bedroom is located at section A and R2’s bedroom is located at section B of the facility far away from each other. Also, R1 was observed very agitated and actively refusing paramedics and police officer transportation to the hospital after removing their foley catheter out. Based on interviews conducted with facility staff (S1, S2, S3, S4 and S5) and residents in care (R1, R2 and R3), statements indicated that there had been incidents of resident-on-resident aggression unrelated to R1, where the facility’s procedure is to reach out to their physicians to review and adjust medications if needed. Although, there had been incidents of resident-on-resident aggressions, it appears like the facility has followed their program plan by addressing the issues with resident’s responsible parties. A finding that the complaint allegation of personal rights is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, May 23, 2024 · control 21-AS-20240409090025

Allegation investigated: -Facility does not maintain a proper fire clearance.

***Amending LIC9099 and LIC9099C. Upon change of ownership on 4/3/23. The secured perimeter was not reviewed by the Department on error. Licensee have submitted pertinent documentation for the Department to review. The Fire Department is engaged and approval is pending. Currently, the facility is operating under fire clarance approved on 11/16/22 without secured perimeter waiver. Complaint disposition will be changed to Unfounded due to facility secured perimeter waiver was not approved. Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Administrative Assistant, Lisa DiBartolo . The Department received an allegation of facility does not maintain a proper fire clearance. Per Reporting Party, on 05/02/2024 an unsafe situation was observed at the front gate was locked and impassable. Administrator’s assistant was sitting at the front desk and failed to inform visitors that the gate was not working. The reporting party attempted to exit from a side gate, which is typically unlocked, and found that gate locked as well. At that point, they went inside to find someone with a key to let them out. On the same date, LPA was conducting a visit for an unrelated situation, Licensee was standing outside of the facility, notified LPA about the issue with the gate code not opening the door every time and escorted LPA through the side gate which was locked at the time of visit. Licensee showed LPA a sign placed on the front door indicating that front door was not working and referring visitors to use side door. Continues on LIC9099C... Unfounded Continued from LIC9099... Based on records review, on 5/3/24 Licensee provided LPA with written communication with the vendor that came to fix the issue on 5/2/24 indicating the following: “This email confirms our appointment for next Tuesday, 5/7/24 at 9-10 AM. As requested, the gate maglock replacement was ordered after our visit in the afternoon of 5/2/24. The gate maglock, exterior button, and inner keypad were all functioning during this visit. We will replace the maglock as agreed upon, ruling out a faulty unit since the maglock is EOL. We will also be installing a new concealed closer inside the gate-welded housing. On 5/7/24, LPA conducted a subsequent visit to the facility. Upon LPA’s arrival, the Licensee and two workers were standing outside replacing the parts at the front door. At approximate 1:13pm, Licensee notified LPA that the door was repaired and was working according to regulation. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. **Immediate Civil Penalty assessed in the amount of $500. ***Amending LIC9099 and LIC9099C. Upon change of ownership on 4/3/23. The secured perimeter was not reviewed by the Department on error. Licensee have submitted pertinent documentation for the Department to review. The Fire Department is engaged and approval is pending. Currently, the facility is operating under fire clarance approved on 11/16/22 without secured perimeter waiver. Complaint disposition will be changed to Unfounded due to facility secured perimeter waiver was not approved.the state’s words, verbatim · CDSS document, May 23, 2024 · control 21-AS-20240502172136

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: May 24, 2024

Type A 87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement has not been met as evidence by: Based on records obtained and interviews conducted with licensee, the licensee did not comply by not ensuring the ability of residents to exit, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 23, 2024

Plan of correction: Facility will ensure all exits are always free from obstructions. Licensee will send in written statement to CCL that they understand and will be complying to regulation 87203. POC due date. **Immediate Civil Penalty assessed in the amount of $500.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Florio and Cuadra arrived unannounced to conduct the required 1-year annual inspection. LPAs met with LIsa DiBartolo, Assistant Administrator and Alex Varshavsky, Licensee arrived shortly after. The facility has residents receiving hospice services and residents with Dementia diagnoses. LPAs observed residents were not participating in any activities. LPAs/Licensee toured the facility inside and outside at approximate 9am: The facility is a one story building and has an approved fire clearance dated November 16, 2022 that allows for 28 non-ambulatory residents and 6 bedridden resident. Fire Extinguishers were last serviced February 2024. Facility has a centralized fire alarm system that is maintained by a vendor and inspected by the local fire department. Facility's last maintenance was conducted 2/14/24. Facility has a locked perimeter. Smoke detectors, sprinklers, carbon monoxide detectors were present throughout the facility. LPAs pulled emergency alerts in residents rooms and staff responded in a timely manner. Fire panel was last inspected 02/14/2024. Last disaster drill was conducted on 03/14/24. Facility had sufficient perishable and non-perishable food. Annual fees are current. At approximate 9:30am LPAs/Licensee observed in communal area and in one resident bedroom, there was a wheel chair stored in front of sliding glass door, obstructing the exit. This poses an immediate safety risk to residents in care. As a result of the fire clearance violation, an immediate civil penalty in the amount of $500 is issued today. At approximate 9:45am LPAs/Licensee observed auditory emergency signal system not working or lacking in 4 out of the 12 client bedrooms inspected. Also, auditory alarms on several resident bedroom sliding glass door exits were not activated. Continue on LIC809C... Continued from LIC809... At approximate 10:00am LPAs/Licensee measured and observed hot water in one resident bedroom tested was 131.6 F, which poses an immediate risk of injury or harm to the residents in that room. At approximate 10:15am LPAs/Licensee observed 2 rusty shower chairs, holes in resident bedroom screen, 2 faucets broken in resident bedrooms, urine smell in resident room, ceiling fans observed covered with thick layer of dust, cement ramp not flush with cement walkway where residents walk, sticky floors in dining area, trash cans without lids/covers, lights not working, and broken electrical plate in resident room. At approximate 10:30am LPAs/Licensee had a discussion regarding activities not occurring during scheduled times. LPAs/Licensee observed posted a current activity schedule. LPAs inquired the reasons for the lack of activity, and were told by administrator assistant that the staff person responsible for conducting the activity was assisting residents. LPAs suggested to designated a back up staff to ensure activity scheduled occurred as planned as stated per regulation. At approximate 10:45 am LPAs/Licensee observed expired canned goods, unpacked dry good not with expiration dates noted, and uncovered prepared foods in the walk-in refrigerator. At approximate 11am LPAs/Licensee observed no menus posted for residents to view. LPAs asked to review a month worth of menus. The administrator did not currently have 30 days of planned menus dated on file. LPAs informed Administrator that per regulation, they shall have menus created and posted two weeks in advance for residents to view in a conspicuous place in facility communal area. At approximate 11:15am LPAs/Licensee observed storage cabinets containing potentially toxic chemicals unlocked in two communal restrooms. Aerosol hair products in drawer were observed in communal area and readily accessible to residents. Additionally, the laundry room door was observed unlocked and unattended with cleaning and laundry chemicals readily accessible to residents in care. Continue on LIC809C... Continued from LIC809C... At approximate 11:30am LPAs/Licensee observed toilet paper and paper towels not available to clients in some client bedrooms and community bathrooms. Lamps and chairs not observed in several client bedroom. Trash cans in common area and in resident bathrooms were observed with no lids/covers on them, one of which had a used bed pad inside. CCL reporting poster not observed in the facility. LPAs Informed Licensee one shall be posted in a conspicuous place in the main entry area of the facility for residents and visitors to reference. Technical violations will be issued. LPAs initiated file review at 12pm. Five residents and five staff files were reviewed. 4 out of five residents (R1, R2, R3 and R4) needs their care plan to be updated. All five medical assessments were updated. 3 out of 5 staff (S1, S2, S3) do not have annual required training hours completed. At least one staff per shift have current CPR. Administrator certificate for administrator Alex Varshavsky 6052513740 expires 7/15/24. At approximately 12:30 a spot check of medications were conducted and 4 out 5 residents (R1, R2, R3 & R4) medications were not given to residents according to their physician's order. Licensee to submit updates of the following documents by 4/25/24: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency Disaster Plan (LIC610E), control of property and a copy of Liability Insurance. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. As a result of the fire clearance violation, an immediate civil penalty in the amount of $500 is issued today. Exit interview was conducted with Administrative assistant who was informed that the Department will be reviewing if further action is needed to address the overall compliance of the facility and a copy of this report was given.the state’s words, verbatim · CDSS document, Apr 18, 2024

The state marks this report as 14 pages; the online copy we transcribed has 10. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management and met with Licensee Alex Varshavsky. The purpose of this case management inspection is to follow up on a couple death reports submitted to Community Care Licensing (CCL). On 1/16/24 CCL received a death report for resident (R1). Per death report, R1 passed away on 1/14/24 at approximate at 2pm while in the hospital. CCL received an incident report notifying CCL of R1's hospitalizations due to signs of congestion. R1 was previously transported to the hospital on 1/2/24 and discharged on 1/3/24. However, based on records review, R1 was not receiving hospice services when they passed away in the hospital. Responsible parties were notified. Also, on 1/14/24 at approximate 1:00pm, resident (R2) passed away while in the hospital. Per incident report, R2 was not receiving hospice services when they passed away. Responsible parties were notified. During today's visit, LPA conducted a visit to review records and follow up the unexpected death of R1 and R2. The investigation found the facility followed all regulation and training requirements. However, R1 and R2 were not receiving hospice services and deaths were unexpected so Licensee agreed to submit death certificate to CCL as soon as they receive it. No deficiencies found during today's inspection. Exit interview was conducted with Licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, Jan 26, 2024

Allegation investigated: Staff did not ensure that resident received their medication as prescribed while in care.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Ana Martinez (Med-Technician). Licensee, Alex Varshavsky was available by phone and gave authorization to staff to sign the report. The Department received an allegation of staff did not ensure that a resident received their medication as prescribed while in care. Per Reporting Party, R1 had been exhibiting behavior issues as yelling, excessive crying, and depression, not wanting to be touched, wandering at night, getting aggressive with staff, when they became aware that the facility has not been ensuring that resident (R1) was receiving their medication (Zoloft-Sertraline) as prescribed by their physician for the last three months, which led them to think that exhibited behavior was the result of missing the medication dosage. On 12/4/23, LPA conducted a 10-day visit to investigate the complaint allegation. Continues on LIC9099C... Substantiated Continued on LIC9099... Based on records review, the facility provided during LPA's visit an incident report dated 12/5/23 indicating the following: “R1’s medication name Sertraline did not get order and R1 was not taking it. Once, we realized that there was an error in our ordering system, the error was corrected, the medication was ordered, and R1 is taking their medication as prescribed”. The facility also provided LPA with the Centrally Stored Medication Log (CSMR) for involved resident, which revealed that Sertraline 100mg/2 times per day (200 tabs supply) date filled was 3/3/23 and the next order was filled until 11/10/23, confirming that R1 was not assisted with the medication since June 2023. Based on interviews conducted with facility staff and outside parties. It was also discovered that the way that the facility is managing resident’s medications was a system where each resident’s medications were placed in their own "little box", and staff were supposed to look at the medication bottle to determine when a refill was due, but in R1's situation they never looked at the refill date so R1 was suddenly no longer getting their Zoloft. This medication is a very dangerous antidepressant due to people are supposed to gradually wean off them and not to be discontinued abruptly as occurred in this case. During records review of facility medication management protocol, it was revealed that the facility has a designated medication technician (S1) responsible for coordinating medication orders and ensuring that they are delivered in a timely manner. However, the designated med-tech is no longer working at the facility. Also, the facility have not contacted a pharmacy to review their medication management at least twice per year as required by regulation. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given.the state’s words, verbatim · CDSS document, Jan 9, 2024 · control 21-AS-20231201111149

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jan 10, 2024

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement has not been met as evidence by: Based on interviews with staff and records review Licensee did not ensure proper management of medication by medication technician staff (S1) who are responsible for medication management of all residents in care which poses an immediate risk to the health & safety of residents in care.the state’s words, verbatim · CDSS document, Jan 9, 2024

Plan of correction: Licensee agrees to conduct a medication audit, retrain staff on medication management from an outside vendor & will write a plan to ensure resident medications are logged into the Centrally Stored Medication Records daily. Licensee to submit the updated plan to CCL by POC due date to clear the citation.