Monarch Cottages La Jolla

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Janet Ngallo conducted a case management – Incident visit in response to an incident that occurred at the facility on 08/09/2026. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Risa Jester. According to the Executive Director, a fire occurred at approximately 4:40 PM on 08/09/2026. The facility contacted the fire department, which responded and extinguished the fire. As a result of the fire, the facility’s sprinkler system activated and caused flooding on the first floor. The second floor of the facility was not affected. Due to the fire and resulting flood, the facility initiated resident relocations. A total of twenty (20) residents were relocated to nearby facilities and other safe locations. Two residents were transported to the hospital as a precaution due to smoke inhalation and/or medical needs. The remaining residents were relocated among neighboring facilities that had available capacity, as the facility’s designated temporary relocation sites listed in the Emergency Disaster Plan had no availability at the time of the incident. The Executive Director reported that one resident is expected to be discharged to a facility after precautionary evaluation, and another resident remains at a hospital due to existing medical conditions and is anticipated to be discharged back to the facility when operations resume. The facility anticipates a temporary relocation timeline of 48–72 hours. The Executive Director stated that there was no damage to the facility kitchen and shared that both the fire department and the Department of Public Health have cleared the facility to resume operations. [Cont. on LIC 809-C] [Cont. from LIC 809] LPA conducted a tour of the facility, including areas impacted by the incident. No additional health or safety concerns were observed during the visit. An exit interview conducted with Executive Director Risa Jester, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058), were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 10, 2026

Allegation investigated: - Staff did not provide two-person assist for resident transfer.

Licensing Program Analyst (LPA) Becky Kennedy conducted an unannounced complaint investigation visit to deliver findings on the above . LPA was granted entry to the facility and met with Risa Jester, Executive Director, after identifying herself and explaining the reason for the visit. The Department’s investigation consisted of review of facility records, outside source records, and interviews of facility staff and outside sources. It was alleged that facility staff did not provide two-person assist for resident transfer. A review of facility records revealed thar Staff 1 (S1) did transfer Resident 1 (R1) without assistance. R1’s care plan requires a two-person transfer for the safety of R1 and staff members. The allegation is therefore Substantiated, and one (1) deficiency was cited for it per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Risa Jester a copy of this report and Licensee's Rights (LIC9058) were provided. Substantiated It was further alleged that facility staff did not follow physician's orders by not insuring resident used Compression Socks Interviews with staff report that they put R1’s compression socks on in the morning, and removed them at night, care staff washed the socks so they would be clean for the morning. This is consistent with resident’s care plan. This allegation is Unsubstantiated It was alleged that facility staff did not follow resident's care plan. Specifically that R1 was in the bathroom and a care giver was further away from the bathroom that they should have been. Interviews and a review of the resident’s care plan states that staff will “Provide as much privacy as possible during bathing” for R1. This allegation is Unsubstantiated. It was further alleged that the facility did not centrally store resident's medication. Specifically that R1’s prescription shampoo and another unidentified medication were in R1’s room. Interviews revealed that medication is taken directly to the med room upon arrival from the pharmacy. Prior to R1’s bathing, facility staff get the prescription shampoo from the medication room and when the care has been provided return it to the medication room. No information was revealed that any other medication was in R1’s room when it should have been centrally stored. This allegation is Unsubstantiated. It was further alleged that facility staff did not ensure R1 was hydrated as evidenced by R1 being hospitalized for dehydration Interview revealed numerous ways staff are trained to encourage liquid consumption by residents and to monitor for signs of dehydration. A review of the “after visit summary” from the period of hospitalization that was specific to this allegation does not mention dehydration as a cause of the hospitalization, R1 was discharged with new medication and referral to a hospice agency. This allegation is Unsubstantiated. Lastly it was alleged that resident’s documents were inaccurate. Specifically that S2 logged that they had come in to assist R1 when S2 did not. Interviews determined that there were logs in R1’s room that were placed there by an outside source. Any such logs or other documents are not facility documentation. No evidence was revealed that the facility’s documentation was not completed accurately. This allegation is Unsubstantiated. Based on interviews and a review of documentation above allegations are UNSUBSTANTIATED meaning that the evidence did not meet the preponderance of evidence standard and is insufficient to compel further action. An exit interview was conducted with Risa Jester; a copy of this report and Licensee's Rights (LIC9058) were provided.the state’s words, verbatim · CDSS document, Mar 11, 2026 · control 08-AS-20210728124213

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Mar 12, 2026

87464 Basic Services (d) … if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs … Based on a review of facility records, S1 transferred R1 without the assistance of another staff member, in violation of R1’s care plan and potentially compromising one of twenty-eight residents in care’s safety.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: Executive director will implement their discipline policy with S! including additional training and a written performance Improvement plan.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Liliana Silveira, made an unannounced visit to conduct the required Annual Inspection to ensure substantial compliance with Title 22 regulations. LPA Silveira was granted entry into the facility by Cognitive Enrichment Director Karen Moran, after identifying herself and stating the purpose of the inspection. The facility serves 52 non-ambulatory residents, age 60 and above, of which 8 may be bedridden. There is an approved Hospice Waiver for 12 residents. This is a two-story complex, equipped with delayed egress and secured perimeters. Currently, there are 18 residents living in the facility. LPA, accompanied by Karen, toured of the facility. The tour was conducted inside and out and included a sample of resident units, the dining area, recreation rooms, and food storage areas. The last disaster drill was conducted on December 18, 2025. No bodies of water are on the premises. Passageways were free from obstructions. According to Karen, there are no weapons and/or ammunition stored on the premises. Signal Systems was available in each resident unit and LPA observed functionality of said system. Delayed Egress and secured perimeter doors were also tested for functionality. Resident's room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens. All extra linens, towels, and washcloth inventory was kept in each resident’s room. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Facility has a two-day supply of perishable foods and a seven-day supply of nonperishable food items. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closet. The medication room is secured and has a locked medication cart, emergency supplies, and medications were labeled and kept in compliance with label instructions. Staff records review verified that all staff records were complete and compliant. Staff records review verified that all staff have a current First Aid certificate and at least one staff member, per shift, has a First Aide/CPR certificate. Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA also interviewed staff and spoke briefly to residents. No deficiencies were cited at the time of visit. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet the residents needs. An exit interview was conducted and this report was discussed with Karen Moran. A copy of the report, along with Licensee/Appeal Rights (LIC 9058 01/2106) were provided to Karen via email. Signature on this form acknowledges receipt of the documents.the state’s words, verbatim · CDSS document, Jan 14, 2026

Allegation investigated: Facility did not meet resident's hygiene needs.

Licensing Program Analyst (LPA) Becky Kennedy conducted an unannounced complaint investigation visit to the facility to deliver findings regarding the above allegation. LPA was granted entry to the facility after identifying herself. LPA met with Karen Moran, LVN Cognitive Entrenchment Director and explained the reason for the visit. The Department’s investigation consisted of LPA observations, a review of facility and outside source records, and interviews of internal and outside sources. It was alleged that the facility did not meet resident's hygiene needs. Specifically, that the facility did not provide for or arrange for proper foot care resulting in Resident 1’s (R1) toenails being uncut and grown significantly beyond the ends of R1’s toes. The investigation determined through interviews and a review of internal and external documents that at the time of R1’s admission to the facility consent was given for R1 to receive podiatry care from an outside provider. Substantiated R1 received podiatry care approximately every two months for a total of four podiatry visits. For reasons that could not be ascertained R1 did not receive any podiatry care after those visits. Interviews revealed that all residents were to receive podiatry care from the identified outside provider unless alternative arrangements had been made. There was not evidence that alternative arrangements were made for R1’s podiatry needs. The investigation did not reveal any evidence of R1 receiving any podiatry care for the last year of R1’s residency in the facility. The investigation revealed the condition of R1’s feet at the time R1 moved out of the facility was consistent with a lack of podiatry care to meet R1’s foot care needs. This condition was the result of the facility’s failure to arrange such care. The allegation is SUBSTANTIATED. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Karen Moran, LVN Cognitive Entrenchment Director a copy of this report and Licensee's Rights (LIC9058) were provided. It was also alleged that facility staff did not keep facility free from incontinence odor. Interviews with internal and external sources and LPA observations did not reveal any concern about odor in the facility on a regular or ongoing basis. This allegation is unsubstantiated. Based on the evidence obtained during the complaint investigation, the above allegations are UNSUBSTANTIATED, meaning the preponderance of evidence standard was not met. An exit interview was conducted with Karen Moran, LVN Cognitive Entrenchment Director, a copy of this report and Licensee's Rights (LIC9058) were provided.the state’s words, verbatim · CDSS document, Jan 12, 2026 · control 08-AS-20210402112310

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(c)(6) · Plan of correction due date: Jan 26, 2026

(c) "Care and supervision" means the facility assumes responsibility for… ongoing assistance with activities of daily living without which the resident’s physical health, … or welfare would be endangered. Assistance includes … personal care. (6) Arrangements to meet health needs… Based on records and interviews the licensee did not arrange for the provision of podiatry care as needed in 1 of 23 persons in care (R1) which posed an potential risk to the health of persons in care.the state’s words, verbatim · CDSS document, Jan 12, 2026

Plan of correction: Facility will add checking hands and feet as part of the monthly skin checklist. The facility will do an inservice trqaining for all caregivers regarding foot care and what issues need to be elivated to nursing staff by POC date. Documentation will be submitted to CCL by POC date.

Allegation investigated: Staff handled resident in a rough manner. Staff did not respond timely to resident’s call button. Facility did not provide adequate incontinence care for resident.

Licensing Program Analyst (LPA) Becky Kennedy conducted an unannounced complaint investigation visit to the facility to deliver findings regarding the above allegations. LPA was granted entry to the facility after identifying herself. LPA met with Risa Jester, Executive Director and explained the reason for the visit. The Department’s investigation consisted of LPA observations, a review of facility and outside source records, and interviews of internal and outside sources. It was alleged that staff handled Resident 1 (R1) in a rough manner. The allegation was that a staff member pulled an item from a resident’s hand. There was no specific object identified in the allegation. Interviews with internal and external sources did not reveal any confirming evidence that R1 or any other resident was treated in a rough manner. This allegation is Unsubstantiated. Unsubstantiated It was further alleged that staff did not respond timely to Resident 2’s (R2) call button in a timely manner. The investigation revealed that the facility care providers all have radios and they check with each other to see who is available to provide care when a call button is pushed. The MedTech on duty is responsible for monitoring the situation and will respond if all care providers are assisting other residents. It was also revealed that almost all calls are responded to from immediately to 10 minutes. On a rare occasion when all caregivers and the MedTech are busy assisting other residents, it might be 15 minutes before care can be delivered. No records were available to confirm response times. “Timely manner” is not specifically defined, however the preponderance of evidence revealed during the investigation did not confirm that response times are of regular concern or that any specific incident was egregious or endangered any resident’s wellbeing. This allegation is Unsubstantiated. It was lastly alleged that the facility did not provide adequate incontinence care for R2. Interviews with internal and external sources revealed that residents are checked every two hours to assess their toileting needs. Excluding the above allegation no concerns regarding resident incontinence care were revealed during the investigation. A review of documents did not reveal any skin breakdown for R1, or other indications of inadequate incontinence care. This allegation is Unsubstantiated. Based on the evidence obtained during the complaint investigation, the above allegations are UNSUBSTANTIATED, meaning the preponderance of evidence standard was not met. An exit interview was conducted with Risa Jester, Executive Director; a copy of this report and Licensee's Rights (LIC9058) were provided.the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 08-AS-20210913092229

Allegation investigated: Staff did not seek medical attention for resident

Licensing Program Analysts (LPAs) Arian Golbakhsh and Iby Strong conducted an unannounced visit to open a complaint investigation and delivered findings regarding the above mentioned allegation. LPAs were welcomed by, identified themselves to, and discussed the purpose of their visit to Executive Director Risa Jester. On 05/27/2025, the Department received a complaint allegation where it was alleged that a resident at the facility identified as (R1) sustained a fall and did not receive medical care. No timeline was provided in the complaint regarding when R1 had fallen. The Department’s investigation consisted of an unannounced facility visit, records review, and interviews with staff, residents, and outside sources. [Continued on LIC 9099-C] Unsubstantiated [Continued from LIC 9099] Interviews with residents did not reveal any concerns regarding timeliness of care received and arrangement of necessary and/or incidental medical attention. Interviews with outside sources indicated that resident medical needs were responded to quickly by the facility. Interviews with staff reveal an established plan for responding to and reporting resident falls. Additionally, staff interviewed did not recall any residents, including R1, having any recent falls. File review of records and outside source medical records corroborated communication with R1's medical providers and contained response plans for R1's care. Based on interviews and records review, there is not a preponderance of the evidence, therefore the allegation have been determined to be UNSUBSTANTIATED. An exit interview was conducted with Executive Director Jester to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jun 4, 2025 · control 08-AS-20250527152121

Allegation investigated: Neglect/Lack of Supervision resulted in resident sustaining serious injury.

Licensing Program Analysts (LPA) Iby Strong and Arian Golbakhsh conducted an unannounced complaint visit to deliver findings in the above-mentioned allegation. LPAs met with Executive Director RIsa Jester and discussed the purpose of the visit. On June 13, 2023, Community Care Licensing (CCL) received a complaint alleging neglect/lack of supervision resulted in Resident 1 (R1) (R1 – see LIC811 Confidential Names List) sustaining serious injuries. According to R1’s Physician Report, R1 is diagnosed with a major neurocognitive disorder, is non-ambulatory, and has motor impairment/paralysis. R1’s Needs and Services Plan states R1 is a total assist with activities of daily living and a two person assist with bathing, washing and toileting. During investigation, the Department collected pertinent resident records as well as facility documentation and conducted interviews. According to the allegation, on an undisclosed date in May of 2023, R1 was being transported and dropped by an unknown staff, resulting in a fracture. According to interviews conducted by the Department, the following sequence of events took place. Substantiated According to Staff 1 (S1) on April 28, 2023, between 7:30pm and 8:00pm, R1 was scheduled to receive a shower. S1 proceed to ask Staff 2 (S2) for assistance in transferring R1 from wheelchair to shower chair. Interview with S2 revealed that S2 assisted S1 in the transfer and left S1 alone to bathe R1. S1 stated that minutes later, S1 reached for a washcloth and as they reached away from R1, R1 fell from shower chair and hit head on the floor. S1 proceed to call for assistance from S2, Staff 3 (S3) and Staff 4(S4). S3 then assisted S1 and S2 in proving first aid to R1 and S4 contacted emergency personnel. R1 was then taken to be medically evaluated and received sutures to left forehead above the eye. According to medical records on April 29, 2023, at 2:56 am, R1 was discharged and returned to the facility with a diagnosis of laceration to the top of the left forehead. Interview with an outside source, confirmed R1 received medical care post fall. Facility status notes revealed that as of May 3, 2023, R1 refused to eat and drink. On May 5, 2023, R1’s responsible party requested for R1 to be evaluated by a medical professional and R1 was then sent out for additional medical follow up. Medical records revealed that at this time, R1 was diagnosed with a closed fracture of left hip and received surgery to treat the fracture. Based on staff and outside source interviews conducted, review of records, including outside sources records, a preponderance of evidence exists to support the allegation neglect/lack of supervision resulted in R1 sustaining a fracture and sutures as a result of not following R1’s care plan. The allegation is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). The Department has determined this violation resulted in injuries to the resident in care. An immediate Civil Penalty of $500.00 is charged and is noted on the LIC421IM. At this time, per Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of Community Care Licensing Division. An exit interview was conducted with Executive Director RIsa Jester, and a Plan of Correction was jointly developed. A copy of this report, LIC811, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Executive Director RIsa Jester, signature on this form confirms receipt of documents. Interview with multiple staff revealed R1 returned from the hospital with a rash sometime in May of 2023. Records collected corroborated R1 was admitted to the hospital in May of 2023 where R1 received extended care for an unrelated medical issue. Interview with staff revealed residents are monitored for incontinence care every 2 hours. It was also alleged that R1 was observed to have pest on their personal items. On June 6, 2023, LPA Strong conducted a facility inspection and did not observe any pests. Interview with multiple staff revealed they have not observed any pest. Interview with an outside source established that they have not seen any pest at the facility. On today’s date, LPAs conducted an additional facility inspection and did not observe any pests. The third allegation states that R1 did not receive assistance with dental care needs. Records collected revealed R1 was scheduled and attended multiple dental appointment in 2023. Interview with staff revealed facility schedules regular dental appointments for residents and will provide transportation to such appointment. Lastly, it was alleged R1 did not receive regular blood sugar monitoring. Interviews with staff revealed that R1 is diagnosed with diabetes but does not require continuous blood monitoring. Records collected corroborated that R1 is diagnosed with diabetes but does not have a diabetic diet or require monitoring. Medical records collected did not reveal any information to establish that facility was not providing adequate care for R1’s diabetic diagnosis. Based on a review of pertinent records and interviews, the preponderance of the evidence standard was not met to prove the allegations. An exit interview was conducted with Executive Director Risa Jester, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 4, 2025 · control 08-AS-20230613182530

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jun 5, 2025

(f) Basic services shall at a minimum include:(4)Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing... This requirement was not met as evidence by: Based on records and interviews the licensee did not provide personal assistance and care as needed in 1 of 23 persons in care (R1) which posed an immediate Safetyisk to persons in care.the state’s words, verbatim · CDSS document, Jun 4, 2025

Plan of correction: Licensee stated staff 1 has been terminated, and training has been provided since the incident for all care staff. Licensee will provide LPA with documentation of trainings within 24 hours.

Allegation investigated: Staff did not follow infection control procedures

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced a follow up complaint investigation visit, and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Congnitive Enrichment Director Alicia Prichard. Throughout the investigation, the Department secured records and conducted interviews with external and internal sources. It was alleged staff did not follow infection control procedures. On 8/23/2024 it was reported to the Department Resident # 1 (R1) was diagnosed with an infectious disease and the facility was not following infection control procedures. Interviews with both internal and external sources confirmed R1 was diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA). Unsubstantiated These sources confirmed R1 developed wounds on R1 legs and R1’s hospice agency requested a lab test, which revealed a positive result for MRSA. Interviews with staff consistently revealed R1 was initially isolated and followed infection control procedures. External sources revealed R1’s hospice agency collaborated with R1’s primary care physician and a wound care provider to provide the appropriate care. Although R1 was allowed to ambulate through the facility, staff maintained the wounds covered and followed general precautions and environmental cleaning procedures to prevent cross contamination. Review of records revealed the facility had provided staff training pertaining to infection control procedures. Based on the evidence obtained during the investigation, the allegation was unsubstantiated. An exit interview was conducted with Prichard, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Jan 28, 2025 · control 08-AS-20240823095237

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and disclosed the purpose of the visit to Cognitive Enrichment Director Alycia Prichard. The facility was licensed for a capacity of fifty two (52) non-ambulatory residents, of which eight (8) may be bedridden. The facility also had a hospice waiver approved for twelve (12) residents, and approved delayed egress throughout the facility. The LPA, accompanied by staff, toured the interior and exterior of the facility. The facility was clean, sanitary, and in good repair. Pathways were free of obstructions and slip hazards. Bedrooms contained the required furnishing and lighting was observed throughout. The signal/call buttons and delayed egress was tested and observed to be operational. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. The were no toxic chemicals accessible to residents and medications were labeled and locked No pools, nor bodies of water were observed on the premises. Per staff, no firearms nor ammunition were kept at the facility. Fire extinguisher(s) were present. Required licensing postings were observed in visible areas of the facility. The LPA conducted interviews and reviewed facility records. No deficiencies were cited during today's annual inspection. An exit interview was conducted with Cognitive Enrichment Director Alycia Prichard, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058), were provided.the state’s words, verbatim · CDSS document, Jan 14, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Director Risa Bishop, after identifying herself and stating the purpose of the inspection. The facility serves 52 non-ambulatory residents, age 60 and above, of which 8 may be bedridden. There is an approved Hospice Waiver for 12 residents. This is a two-story complex, equipped with delayed egress and secured perimeters. LPA was accompanied Director Bishop during a tour of the facility. Tour was conducted inside and out and included a sample of resident units, the dining area, recreation rooms, and food storage areas. The last disaster drill was conducted on December 21, 2023. No bodies of water are on premises. Passageways were free from obstructions. According to Director Bishop, there are no weapons and/or ammunition stored on the premises. Signal Systems was available in each resident unit and LPA observed functionality of said system. Delayed Egress and secured perimeter doors were also tested for functionality. Resident's room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens. All extra linens, towels, and washcloth inventory was kept in each resident’s room. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closet and outside storage area. The medication room is secured and has a locked medication cart, emergency supplies, and medications were labeled and kept in compliance with label instructions. Staff records review verified that all staff records were complete and compliant. Staff records review verified that all staff have a current First Aid certificate and at least one staff member, per shift, has a First Aide/CPR certificate. Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPA conducted a review of In-service training procedures. LPA interviews with Director Bishop confirm residences are provided with assistance necessary for medical and dental appointments. LPA reviewed the theft and loss policy and procedures. No deficiencies were cited at the time of visit. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. An exit interview was conducted, this report was discussed with Director Bishop, a copy along with Licensee/Appeal Rights (LIC 9058 01/2106), and their signature on this form acknowledges receipt and a copy of the report was given to the Director Bishop.the state’s words, verbatim · CDSS document, Jan 9, 2024

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.