Muirwoods Memory Care

Allegation investigated: Staff mismanaged resident's medications.

At approximately 8:20 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegation and met with Operations Specialist (OS) Brenda Mercer. During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents. Complaint alleges that staff mismanaged resident’s medication. Witness W1 provided the Department of Social Services with copies of resident R1’s Centrally Stored Medication and destruction records. LPA confirmed the validity of the documents provided by W1. Medications for R1 are ordered in a thirty (30) day cycle. Based on the thirty (30) day cycle the facility will need to order an additional five (5) pills for standard (non-leap day) year. There were two (2) out of cycle orders for Medication-1 (Med-1). On 3/10/2026 the facility’s pharmacy filled an order for twelve (12) Med-1 pills. On 4/15/2026 the facility’s pharmacy filled an order for six (6) Med-1 pills. Continued on 9099-C... Substantiated ...Continued from 9099 According to pharmacy staff member witness 2 (W2) all out of cycle orders are placed by the facility. Review of Medication Administration Records (MARs) do not show any missed or double doses of Med-1. LPA interviewed staff members S2 and S3. Neither staff member was able to state exactly why the additional pills were ordered. Additionally, correspondence from staff member S1 in reference to Med-1 states, “In some cases, variances can also occur due to factors such as medication handling, including potential waste, though we do not have documentation confirming this in this instance.” 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 (CCR), Title 22, Division 6 Chapter 8, 87465(a)(4) are being cited on the attached 9099D. As the facility has been previously cited for this deficiency on 5/14/2026, a Civil Penalty of $250 is being assessed. ...Continued from 9099-A Complaint alleges that the facility does not communicate with resident’s responsible party. California Code of Regulations, Title 22, Division 6, Chapter 8, Article 4 Operating Requirements, 87211 reporting requirements states: (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, in route to or from a hospital, or visiting away from the facility. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. (C) The use of an Automated External Defibrillator. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. LPA reviewed resident R1’s admission agreement and their individual service plan and did not see any additional communication requested regarding resident R1. LPA requested from the facility a copy of all communication between the facility and resident R1’s responsible party from 5/1/2026 to 6/4/2026. LPA observed numerous emails between the facility and resident R1’s responsible party. 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. Copy of report, LIC-9099, LIC-9099-C, LIC-9099D, LIC-421FC, Plan of Corrections, Appeal Rights, LIC-9099A and LIC9099A-C discussed and provided to OS Brenda Mercer. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 10, 2026 · control 21-AS-20260602225438

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 11, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interview & record review, the licensee did not comply with the section cited above in that facility staff cannot explain why thirteen (13) pills of Med-1 were ordered out of cycle which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: Facility to update its Medication Administration plan to ensure that all non-cycle medication orders are recorded. This record should show who, and why a non-cycle medication was ordered. Additionally, facility is to retrain all Medication Technicians in Medication Management record keeping. Proof of training and updated plan to be sent to Community Care Licensing by POC due date of 9/11/2026.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Star Stevenson arrived unannounced at the facility to conduct a Case Management Incident Visit and met with Operations Specialist and interim Administrator Brenda Mercer. The purpose of this case management inspection is to follow up on late reporting of Incident Reports (SIR’s) & self-reported SOC 341’s submitted to Community Care Licensing (CCL). LPA Hansen advised in June of 2026 of Reporting Requirements due to then, no incident reports (IR’s) had been submitted in May or June of 2026. On July 1st, 2026 facility submitted 3 Incident reports from May and 2 SOC 341’s from June 16, 2026. On August 20th, 2026 LPA Hansen contacted facility due to not receiving IR’s since 6/2026 and was informed the task of submitting the IR’s was allocated to a PM shift staff that had apparently not submitted. On 8/21/2026 the Director of Health & Wellness submitted 4 IR’s (2 current & 2 late from 8/11/2026) they followed up on 8/25/2026 by submitting 5 additional late IR’s (6/24/2026, 7/8/2026, 7/16/2026, 7/15/2026, & 7/21/2026). On 8/27/2026 the department received 2 late SOC341’s that occurred on 8/1/2026 & 8/18/2026. Regulation - Reporting Requirements 87211(a)(1) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: Continued on 809-C Continued from LIC809 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. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights providedthe state’s words, verbatim · CDSS document, Sep 1, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Sep 4, 2026

87211 (a)(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 requirement not met as evidenced by: During review Incident Reports in 8/2026, LPA observed no IR’s had been reported to CCL since 7/1/2026 and CCL received 7 late IR’s & then 2 late SOC341’s which poses/posed a potential risk to the Health, Safety and Rights of residents in care.the state’s words, verbatim · CDSS document, Sep 1, 2026

Plan of correction: Licensee to self-certify that the management team at Muirwoods Memory Care has reviewed CCR 87211(a)(1) of Reporting Requirements and submit to Community Care Licensing (CCL) a plan for Muirwoods to meet regulations set fourth by CCR 87211(a)(1) by End of Business (EOB) day 09/04/2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced at facility to conduct a Case Management Incident Visit and met with Interim Executive Director, Brenda Mercer. The purpose of this case management inspection is to follow up on a self-reported SOC 341, submitted to Community Care Licensing (CCL). On 07/09/2026 CCL received an SOC341 from facility reporting abuse that occurred at the end of April, 2026 and was relayed to management May 27,2026. During today’s inspection LPA conducted interviews and obtained records. LPA will review information, conduct additional interviews, and follow up with facility. No citation issued during today’s visit.the state’s words, verbatim · CDSS document, Jul 14, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced at facility to conduct a Case Management Incident Visit and met with Administrator, Grant Haywood. The purpose of the visit was to follow up on self-reported incident that was submitted to Community Care Licensing (CCL). CCL received an incident report on 6/22/2026. The report stated that on 6/15/2026 at approximately 10:30pm a door alarm was activated and Resident (R1), who has a diagnosis of dementia and is unable to leave facility unassisted, eloped from community. Staff responded to alarm but did not conduct exterior search or head count of residents. At approximately 12:20 AM, R1's POA contacted facility indicating R1 was with Law Enforcement who had contacted POA after R1 had been going to homes adjacent to community for approximately 2 hours and one neighbor had contacted Law Enforcement. R1 was brought back inside community by Law Enforcement after being located in parking lot. R1 was assessed at facility, no injuries sustained. During today's visit, it was revealed to LPA that R1 had exited by east side door next to apartment right after cross over when PM shift informs NOC shift of days current events. Per R1’s Physician’s Report (LIC602) 1/13/2026, R1 is diagnosed with dementia and is unable to leave the facility unassisted. (Deficiency cited). Some elopement training's have been conducted & disciplinary action taken for 2 caregivers. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights providedthe state’s words, verbatim · CDSS document, Jun 22, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jun 25, 2026

Personnel Requirements – General 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement was not met as evidenced by: Based on interviews and file review, facility did not provide supervision to R1 resulting in an elopement. The absence/lack of supervision is an immediate risk to the Health, Safety and Rights of residents in care.the state’s words, verbatim · CDSS document, Jun 22, 2026

Plan of correction: Licensee/Administrator to submit in-service retraining to all staff on elopement protocols. Trainings & Documents to be submitted to LPA by POC due date 6/25/2026. Disciplinary action taken on 2 care givers -

Allegation investigated: Staff did not ensure residents care needs were met

On 06/19/2026 Licensing Program Analyst (LPA) arrived unannounced to deliver complaint findings on the above complaint allegation. LPA met with Tolu Faaita-Business Office Manager who has Designation of Faciltiy Responsibilty (RP) On 04/14/2026 Community Care Licensing (CCL) received a complaint from Reporting party that on 04/10/2026, “care staff never showed up for their shift and resident (R1) was neglected all day” In addition, the reporting party stated that, “a few other residents that, day were also neglected” On 04/20/2026 LPA conducted an unannounced visit to Muirwoods Memory care, made observations, conducted interviews and obtained documents. The investigation revealed that (1) staff scheduled for the PM shift on 4/10/2026 did not show up as scheduled. The facility contacted a staff member to cover the shift who arrived approximately two hours later. Continued on LIC9099-C Unsubstantiated Continued from LIC9099-C LPA interviewed four (4) witness visitors who raised no concerns for lack of staffing leading to care neglect. On 06/19/2026 LPA conducted subsequent interviews with four (4) staff which revealed no supporting information that residents’ care needs are not being met. LPA obtain emails related to staffing and care concerns, Care Notes for R1 through April 11th, 2026, as well as a staffing schedule and adjustments to staffing made on April 10th, 2026. LPA also obtain a Physicians Report and Admissions Order (LIC602) for R1 dated 01/12/2025, a Service Plan for R1 dated 01/08/2026, and Assisted Living Resident & Service Agreement dated 06/12/2024 Finally, LPA obtained copies of Petaluma Police Incident/Investigation report dated 04/14/2026 which indicated physical signs of neglect or elder abuse to be unfounded. Due to conflicting information obtained as to whether R1’s care needs were met or not met in the afternoon and early evening of April 10th, 2026, the allegation of “Staff did not ensure residents care needs were met” is unsubstantiated. An allegation of Unsubstantiated means although the allegation may have occurred or may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.the state’s words, verbatim · CDSS document, Jun 19, 2026 · control 21-AS-20260414084720

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by concierge. Interim Department of Health Services (DHS) Faveola York worked with LPA until Administrator (Admin) arrived. Administrator Grant Haywood arrived later. Grant Haywood Administrator Certificate 7039094740 expires 8/6/26. All fees are current as of this time. Fee notification given to Admin along with PIN for online payment. Facility currently has 42 residents in care nine (9) of which are currently on hospice. At approximately 9:30am LPA and DHS toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled with opened dates present. LPA observed kitchen cleaning products located on a shelf very back of kitchen, away from food preparation. LPA and Director of Dining Services (DDS) discussed adding a cabinet in which to store the disinfectants and cleaning products utilized in the kitchen. DDS will request from Admin immediately. All other cleaning supplies and laundry soaps are located in the laundry room or in cleaning carts, inaccessible to residents in care. LPA and DHS toured room # 3, #10, and #17. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sinks measured at 116.4 degrees F in room #3, 115.2 degrees F in room #10, and 114.4 degrees F in room #17, all of which are within the allowable range of 105 to 120 degrees F. Facility has common bathrooms used by residents, staff, and guests. Faucets in these bathrooms are turned on by hand sensor. Hot water is an Continued on 809C... Continued from 809... option by turning lever all the way back. LPA discussed with Sean Elser Maintenance Director (MD), functionality of faucets and that lever should be set such that the hot water temperature remains within compliance which is a range of 105 to 120 degrees F. Fire extinguishers were last inspected 11/18/25. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired and serviced by vendor. Vendor annual inspection was last conducted 11/6/25 all systems pass. Facility’s last quarterly disaster drill was conducted on 4.29.26. Facility has a backup generator for use during a power outage. LPA and MD toured outside of facility and emergency shut off sites for water, gas, and electric were all observed. LPA and DHS toured courtyard area. LPA observed two (2) table umbrellas providing shade. Facility has a gazebo in courtyard, but it does not provide shade. LPA and DHS discussed adding a top to the gazebo to provide shade, considering they have a capacity of 80. A shaded gazebo would act to provide much more shaded area. LPA observed video surveillance in resident rooms, signed notices all on file. LPA observed oxygen in use, sign present on door. At approximately 12:30pm LPA conducted a review of six (6) staff files. Staff do not have the required hours of training completed (deficiency cited, see 809D). Of the files reviewed, two (2) staff started within 12 months, but neither of them had the required numbers of hours and subjects matters completed within the 1st 4 weeks of employment. Additionally, of the six (6) files reviewed, LPA reviewed four (4) Medication Technician (MedTech) files. S2 and S3 MedTechs did not have the required medication training completed on file (deficiency cited, see 809D). At approximately 2:00pm LPA conducted review of eight (8) resident files. Residents R1, R3, R4, and R5 all had physician reports that were not current (deficiency cited, see 809D) At approximately 3:00pm LPA and MedTech conducted a spot check of medication and medication records. Medication is centrally stored in a locked room. Facility is required to have a medication management program review completed with a pharmacy every six months, date of last review for facility was 9/19/25 (deficiency cited, see 809D). Continued on 809C(2)... Continued from 809C... LPA reviewed medications and Centrally Stored Medication log for R7. Two (2) errors were found. Prescription for Zinc Oxide ointment not listed on CMSL (deficiency cited, see 809D). Bubble pack for Escitalopram 20mg had a start date of 4/21/26 and a beginning quantity of 30, but only four (4) pills remain, so bubble pack is missing 2 tabs (deficiency cited, see 809D). Facility does not have tracking system for medications that accidentally fall on floor or such accidents. Additionally, LPA observed pre-pouring of medication (deficiency cited, see 809D). LPA and Admin discussed Emergency Disaster Plan. Admin confirmed no updates needed. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance 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 Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, May 14, 2026

Type of visit: Case Management - Incident

At approximately 2:50 PM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management inspection and met with Executive Director/Administrator, Heather Montgomery. The facility submitted one (1) Incident Report (IR) for Resident 1 (R1) for a medication error. On 3/1/2026, Medication Technician (staff member S1) missed administration of a medication for resident R1. The medication was prescribed to be given at 3:30 PM. The medication was given to resident R1 at approximately 6:21 PM, three (3) hours later than the prescribed time. Resident R1's emergency contact and resident R1's Primary Care Physician were notified. Resident R1 was monitored by the Director of Health Services and no adverse reactions were observed. The facility will be cited for this medication error. The facility took disciplinary action against staff member S1. Additionally, the facility conducted Medication policy training for all Medication Technicians (Med Techs) on 3/6/2026 and 3/10/2026. As the facility has already conducted Medication Policy Training for all Med Techs, the deficiency will be cleared during today's visit. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Executive Director Montgomery. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 10, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 11, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical... shall be developed...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interview & record review, the licensee did not comply with the section cited above in that medication for R1 was administered approximately three (3) hours later than the prescribed time which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 10, 2026

Plan of correction: Licensee or Administrator will submit proof of Medication Policy training for all of the facility's Medical Technicians to Community Care Licensing by POC due date of 3/11/2026.

Allegation investigated: -Staff not preventing outbreak of scabies. -Staff does not provide medical attention to residents.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with heather Montgomery (Administrator). There is an allegation of staff not preventing the outbreak of scabies. According to the reporting party almost 98% of residents (unknown names) have scabies and they are not receiving care for their scabies including ointments. During the course of the investigation, LPA Hansen conducted interviews, made observations and reviewed records. On 10/28/25 LPA conducted a 10-day visit and made observations while residents were eating their lunches, two residents (R1 & R2) were observed scratching themselves. Based on records review, the facility provided R1’s care notes entered by a third-party agency on 10/31/25 at 4:16pm; They are assisting R1 with unrelated conditions and were notified by the facility that R1 was scratching their abdominal area, but no rash was observed. Also, R2’s physician report determines that R2 has been regularly treated by their physician for a history of itchy skin on arms and legs due to a previous diagnosis that affects their skin condition. Continue on LIC9099C... Unsubstantiated Continued from LIC9099... R2’s care notes entered by a third-party agency for the month of October 2025 confirmed that they are providing treatment and the facility was instructed to follow CDC guidelines. Additionally, the facility has previously implemented a plan to address this ongoing issue including a prophylactic approach along with daily skin monitoring of the residents, they were instructed by the Department of Public Health to implement CDC guidelines including isolation and deep-cleaning preventive measures. A finding that the allegation of staff not preventing the outbreak of scabies 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 regarding staff does not provide medical attention to residents. Per Reporting Party, facility staff are aware that about 98% of the residents (unknown names) have scabies, but the facility are not scheduling doctor’s appointments, and no actions are being taken to prevent the outbreak. LPA Hansen attempted unsuccessfully to speak with complainant on 10/22/25 at approximately 11:02am, 10/24/25 at approximately 1:29pm and 10/27/25 at 8:25am to gather additional information. Based on interviews conducted by LPA on 10/28/25 and 11/25/25 with staff (S1, S2, S3, S4, S5 & S6) and third-party agencies (I1), it indicates that back in August was the last time that a confirmed case of scabies was discovered, then back in September a resident was treated, but not confirmed. LPA reviewed incident report logs for this facility and both incidents were reported to the Department as well as to the resident’s responsible parties as stated in regulations. LPA is unable to determine if any other incidents have happened at a different date and the complaint did not provide any additional information that could lead the investigation to a specific resident or date when these incidents might occur. The finding that the allegation of staff does not provide medical attention to residents 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, Feb 18, 2026 · control 21-AS-20251020122315

Type of visit: Office

An informal meeting was conducted today in the Santa Rosa Regional Office as requested by Petaluma Fire Department to discuss areas of concerns. Present in the meeting were Regional Manager Carla Nuti-Martinez, Licensing Program Manager Bethany Moellers, Licensing Program Analyst Marisol Cuadra, Fire Department Representative Melissa Leonelly, Executive Director/Administrator Heather Montgomery, and via Microsoft Teams Executive Director of Senior Advocacy Services Crista Barnett Nelson,. During today's meeting, it was discussed concerns regarding calls for service not limited to lift assists, wound care and falls where residents did not have injury. The Department has reviewed incident reports submitted and facility protocols appears that calls for service were adequate for the level of care that the facility is allowed to provide to residents in care and the Fire Department could be contacted to assess residents and determine if further evaluation at the hospital is needed, as the facility is non-medical and not able to make that determination. Administrator agrees to submit by COB 3/4/2026 Updated infection control plan Policy related to 911 protocol Policy related to resident assessment after fall(s) Update LIC500 Personnel Report. No deficiencies cited during today's office meeting. Exit interview conducted with the Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Feb 18, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Case Management Inspection and met with Administrator Heather Montgomery. The purpose of this case management inspection is to follow up on a self-reported SOC 341, submitted to Community Care Licensing (CCL). On 11/07/2025 CCL received an SOC341 from facility reporting abuse on 11/06/2025. During today’s inspection LPA conducted interviews and obtained records. LPA will review information, conduct additional interviews, and follow up with facility. No citation issued during today’s visit.the state’s words, verbatim · CDSS document, Nov 25, 2025

Allegation investigated: Staff are not safeguarding resident's personal belongings Staff are not providing adequate laundry services to residents in care

Licensing Program Analyst (LPA) Hansen arrived unannounced to deliver investigation findings to the allegations listed above. LPA met with Administrator, Heather Montgomery. During the course of this investigation LPA conducted 2 facility visits on 9/9/2025 & 10/7/2025 making observations, obtained facility documents, and conducted 11 interviews with staff, residents, and outside parties. Staff are not safeguarding resident's personal belongings & Staff are not providing adequate laundry services to residents in care - Complainant alleges that relatives have found their loved ones clothing being worn by other residents and their clothing have been missing and never found. As well relatives cannot depend on the staff to wash the residents clothing in a timely manner and return to owner. Interview with staff (S1) revealed an Interim executive director changed the laundry system a few months ago replacing individual staff who did laundry with caregivers doing laundry. Continue on LIC9099C Substantiated Continued from LIC9099 Corporate has been informed there has been many problems with this change including needing a specific laundry person as resident cloths are being put in different resident rooms/lost and some being ruined/shrunk. Interviews with S4 & S5 corroborate laundry is being misplaced and some cloths are missing. Outside party, Individual (I1) also indicated there is laundry missing since the change and is not getting back in a timely manner. Interview with resident (R1) revealed they have lost cloths to the facility laundry as well when the laundry was returned items were shrunk, family is now doing all of their laundry. Obtained Laundry Log from 7/26/2025 to 8/21/25 (4 pages) all 4 pages missing filled in columns of either room numbers , washer used, time put in dryer, or dryer used, time finished and by whom. As well, many different staff who handled laundry only a couple staff filled out log completely. New Administrator, Heather Montgomery as of 9/10/2025 confirmed on 10/7/2025 there was a change in the laundry system some months ago and there still seems to be cloths misplaced and lost. The facility is working on implementing the old system. During today's visit 10/28/2025 Administrator informed old system was reinstated on 10/1/2025. It was revealed resident items were not being safeguarded due to facility not having adequate laundry service. Based on LPA's observations and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations Staff are not safeguarding resident's personal belongingsand Staff are not providing adequate laundry services to residents in careare found to be SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided Continued from LIC9099A Health and Safety Code Regulations 1569.158 states: Family councils (f) If a family council submits written concerns or recommendations, the facility shall respond in writing regarding any action or inaction taken in response to the concerns or recommendations within 14 calendar days. The facility has submitted over a page of answers pertaining to the questions/concerns provided from the first family council meeting held 8/16/2025 and did not respond to 2nd council meeting as there were no concerns submitted. There was no information obtained that supported that a violation had occurred. Therefore the allegation is Unsubstantiated. Facility did not notify of fee changes per regulation – Complainant alleges the facility said they would be implementing an increase in their charges for laundry after the family council complained and after having the same fee schedule for over a year and a half. Facility Admission agreement indicates one personal load of laundry per week for everybody's laundry. Agreement also indicates additional loads would be $20.00 per load. Resident Assessments reviewed dated 9/2025 did not show any points for laundry services. Interview with Business Office Manage and Administrator revealed as of 10/28/2025 no family /resident has been charged extra for laundry services, not even when the need arises with soiled bedding or laundry or spills. There was no information obtained that supported that a violation occurred. Therefore the allegation is Unsubstantiated. Based on the interviews, record/document reviews, and related information obtained during the investigation the allegation's Facility is not responding to the family council and Facility did not notify of fee changes per regulation are 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.the state’s words, verbatim · CDSS document, Oct 28, 2025 · control 21-AS-20250904040256

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(F) · Plan of correction due date: Oct 28, 2025

87307(a)(3)(F) Personal Accommodations and Services: (F) Basic laundry service (washing, drying, and ironing of personal clothing). This requirement is not met as evidenced by : Based on interviews, observations, and records reviewed Licensee did not ensure resident laundry was completed, leaving laundry in other residents’ rooms, not finishing laundry in an appropriate time. This poses a potential Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: New Administrator has reinforced old laundry system with a main staff conducting 5 days a week with NOC shift completing remainder from the day that was not, by laundry staff. And another primary from housekeeping is doing other 2 days regularly. Reinstatement of old laundry system started 10/1/2025. POC cleared at visit.

Type of visit: Case Management - Other

LIcensing Program Analyst (LPA) Hansen arrived unannounced at facility to conduct a case-management and met with Interim Executive Director (IED) Heather Montgomery. IED has been at facility since 9/2/2025. CCL has requested required documents to change Administrator. IED informed they have spoken to corporate and will provide requested documents by EOB Thursday 9/11/2025. No Citations given at today's visit.the state’s words, verbatim · CDSS document, Sep 9, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Health and Safety inspection and met with Karina Medina, Administrator & Lupe Villa -Guerrero Director of Health Services. This full dementia facility has 49 residents in care. Upon arrival on 9/2/2025 at 1:30 PM LPA toured facility and observed 13 staff, facility to be clean and at a comfortable temperature with no exits obstructed and enough food per regulation. No immediate concerns noted. There were no deficiencies cited during today’s visit.the state’s words, verbatim · CDSS document, Sep 2, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Hansen arrived unannounced at facility for the purposes of conducting a Subsequent visit from initial date 3/20/2025. LPA met with Carolina Rodas-Reyes, Head Medication Technician, a designee as all Management is off for the holiday, but spoke with on phone who authorized Head Medication Technician to sign for todays visit. LPA conducted interviews, and made observations. No citations given during today’s visit.the state’s words, verbatim · CDSS document, Jul 3, 2025

Type of visit: Required - 1 Year

License Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required - 1 Year inspection of the facility. LPA met with Administrator Karina Medina. This single story senior living community is a full memory care facility with 40 apartments. Facility has a fire clearance by Petaluma Fire Department for 80 non-Ambulatory residents and has a Hospice Waiver approved for 20. There is a total of 48 residents with 13 residents currently receiving Hospice services. LPA toured the facility on 04/18/2025 at 9:45 AM with Administrator and Director of Health Services (DHS) Lupe Villa-Guerrero; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The tour of the facility included nine resident apartments, activity rooms, Library, music room, dining rooms, kitchen and outdoor patios & courtyard. Facility serves residents with dementia and has special care plan of operation and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. Food was found to be handled and stored in a safe manner. Facility kitchen has a binder with all resident’s names and their needs. Menu is posted. Food is available for residents any time of the day. Fire Extinguisher was found to be last charged on 12/6/2024 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected by a vender with the last inspection being conducted on 11/15/2024. LPA observed Carbon monoxide detectors that were found to be operational during the visit. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Continue on LIC 809-C Continue from LIC 809- Hot water temperature measured between 108.6 degrees F and 115 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 9 of 9 resident’s bathrooms while touring facility. Resident bathrooms had required slip resistant mats and grab bars. Toxins are stored in a locked housekeeping room; although at 10:05am LPA & Administrator observed Janitorial Closet on Side 1 left ajar/open with toxic cleaning chemicals accessible to residents in care (see LIC809-D). During inspection LPA & Administrator observed 26 missing window screens on the inside courtyard & exterior of facility, along with additional damaged screens (see LIC809-D) Regional Director of Health & Wellness informed, there is a screen project with repair service to come out and repair & replace window screens. There was a supply of cleaners, hygiene products and paper products available for residents. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Beds were outfitted with mattress pads as required by Title 22 Regulations on 4/18/2025 at 10:30 AM. A sample review of six resident & six staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 12:15 PM on 4/18/2025 and learned that 6 out of 6 residents have an updated reappraisal/needs & care plan on file as well as medical assessments at this time as required by Title 22 Regulation. Medications were centrally stored in two locked medication carts in the facility medication room. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 4/18/2025 at 2:30 PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. LPA conducted a sample reviewed of staff records at 1:30 PM on 4/18/2025 and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received the additional training requirements as per Title 22 Regulations and H&S Code. LPA was presented with proof of CPR & 1st Aid certification for required staff. Disaster Drills have been conducted quarterly in different shifts with the last one being conducted on 3/20/2025. In case of disaster and power goes out, facility has a permanent generator that self tests once a week. Karina Medina Administrator Certificate # 6076069740 expires on 3/11/2027. Continue on LIC809-C Continued from LIC809-C Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. LPA Hansen is requesting Licensee to update the following documents by 5/7/2025: LIC 308 Designated -if changes LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan – if changes LIC 9020 Register of Facility Client’s/Resident’s Copy of Administrator Certificate Copy of Certificate of Liability Insurancethe state’s words, verbatim · CDSS document, Apr 18, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Hansen arrived unannounced at facility for the purpose of conducting a Case Management regarding a self-reported incident report & SOC 341 from facility received on 3/18/2025 of alleged sexual assault. LPA met with Director of Health Services. LPA obtained documents. No citations given during today’s visit.the state’s words, verbatim · CDSS document, Mar 20, 2025

Allegation investigated: Staff do not ensure that a resident's incontinence needs are met

While conducting informal office meeting in the Santa Rosa RO, Licensing Program Manager (LPM) Moellers & Licensing Program Analyst (LPA) Hansen delivered findings on the above complaint allegations to Administrator Camille Brown. Staff do not ensure that a resident's incontinence needs are met– Complaint alleges that the facility is understaffed, resulting in staff not changing resident’s incontinence briefs regularly, causing the resident to wear soaked briefs. Pictures were provided showing resident in two briefs. Complaint also alleges that staff are double briefing and that staff do not clean resident thoroughly when changing their briefs. Complaint alleges that resident has behaviors resulting in a 30-day eviction, but complainant believes that the behaviors are the result of multiple urinary tract infections. Three of five staff interviewed indicated that they have observed, heard of, or have themselves double briefed residents in care with one staff admitting they double briefed to combat frequent urination, Continued on LIC9099-C Substantiated Continued from LIC9099 - therefore the allocation Staff do not ensure that a resident’s incontinence needs are met is substantiated, meaning the preponderance of evidence standard has been met, the above allegation is found to be SUBSTANTIATED Appeal of Rights Given. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Continued from LIC9099-C Staff do not ensure that a resident's personal care needs are met – Complaint alleges that staff are not cleaning and washing resident when toileting and that staff are not washing hands before and after assisting resident with personal care needs, such as brushing teeth. LPA conducted interviews but was not able to confirm instances where staff may not have washed their hands or cleaned/washed residents during personal care assistance. LPA is unable to obtain supporting evidence to determine staff are not distributing resident’s medication as prescribed or staff are not cleaning and washing resident when toileting, therefore allegations are unsubstantiated. A finding that the complaint allegations of Staff are not distributing a resident's medication as prescribed and Staff do not ensure that a resident's personal care needs are met 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, Jan 29, 2025 · control 21-AS-20240719150606

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jan 30, 2025

87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement was not met as evidenced by: Bases on pictures provided and staff interviews facility did not comply with above regulation regarding incontinence care needs being met and staff double briefing. This poses an immediate Health and Safety risk to clients in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Facility Administrator to submit a written response on how they handled the situation by 1/30/2025.

Type of visit: Office

An informal meeting was conducted today in the Santa Rosa Regional Office with some participants via Microsoft Teams. Present in the meeting were, Licensing Program Manager, Bethany Moellers, Licensing Program Analyst, Shannan Hansen, Administrator Camille Brown & Kimberly Kooy, Reg. DHW via Teams - Courtney Lane, Regional Dir. of Opps. and Denise Munoz, Corporate Dir. of Administration. The purpose of the informal office meeting is to discuss civil case judgement that was determined in August 2024 and if there were any solvency concerns with the facility, as well, delivering complaint findings of 21-AS-20240719150606. Administrator informed there are no concerns regarding facilities financial solvency. The following was discussed during the office meeting: · Solvency Issues due to civil case judgement · Findings of complaint 21-AS-20240719150606the state’s words, verbatim · CDSS document, Jan 29, 2025

Allegation investigated: -Resident sustained unexplained bruising 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 Administrator/Executive Director Camille Brown. The Department received an allegation of resident sustained unexplained bruising while in care. Per reporting party, resident (R1) had bilateral bruising on forearms possible injuries appeared to be inflicted by another. On 4/3/24 the staff was asked about it, but it apparently staff said they asked around and no one saw resident screamed out or anyone go near to them to injure R1. R1 was observed with a band-aid on their forearm so someone had to have seen the bruising. Based on records review, on 10/7/24 LPA was provided by an outside party with pictures supposedly taken on 4/2/24 of R1 with bruising noted in their arms along with an office visit note and e-Prescription dated 4/2/2024 where a physical exam was performed describing scrapes, bruises, and extreme itching with several cuts mainly on right arm, bruises on their lower arms, hands, and wrists; lacerations and skin tears that appear to be from fingernails. Continued on LIC9099C... Unsubstantiated Continues from LIC9099... Hydroxyzine 25mg tablets were ordered for itching/anxiety. The facility provided R1’s records including physician’s report dated 8/25/23 does not indicate any history of skin condition/breakdown at that time. Although, physician’s order dated 2/26/2024 for Ivermectin 3mg tablets for treatment of scabies. On 3/26/24, R1 had an in-person visit with their physician, who prescribed medications not related to the bruising. However, there were no bruising observed during that in-person visit to their physician. According to facility narrative charting provided to LPA describes that on 3/28/24 R1 was walking down the hall, skin tear and blood was observed on their right forearm, it was cleaned by staff (S1) who placed a band aid and Wellness Director was notified, but the facility did not seek for medical attention for R1, because their policy states that bandage only needed, did not require staff to notify the responsible parties. LPA will address medical attention in a case management due to facility did not seek any further medical attention. On 4/2/24 the facility received a call from R1’s responsible party notifying the facility about R1’s bruising and a bandage that was falling off. On 4/5/24, The Department received SOC341 along with incident reporting suspected physical abuse with unknown suspected abuser. The SOC341 was generated upon request of an outside agency on 4/3/24 after noticing that the facility have not adequately reported R1’s bruising and what appeared to be digging of nails looked like abuse. Based on interviews conducted with outside parties and facility staff, it was determined that on 4/8/24 there was a conference meeting held to discuss the issue. On 4/4/24 staff training records confirmed that staff have received mandated reporting training. Moreover, verbal statements obtained from interviews with involved parties reflects contradictory information and there was no indication to determine the reason of R1’s bruising. According to police records, case #24-3919 has a conclusion of “suspended” status due to other unrelated factors. Based on records review and interviews, LPA is unable to obtain supporting evidence to determine the reasons of R1’s bruising on their forearms. A finding that the complaint allegation occurs of resident sustained unexplained bruising while in care 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, Jan 7, 2025 · control 21-AS-20241002083624

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cuadra conducted a case management visit to cite deficiencies discovered during a complaint investigation and met with Administrator/Executive Director Camille Brown. LPA learned through records review and interviews that facility staff did not seek any medical attention from resident’s (R1) physician after noticing R1’s bleeding on 3/28/24 by facility staff who cleaned and place a bandage on R1’s right arm. According to facility narrative charting as dates progressed, R1 was on a shower schedule of every other day, but R1 refused to shower the morning of 4/2/24. However, the entry was entered late on 4/8/24 at 6:51pm. On 4/2/24 the facility was notified about R1’s bruising noticed by their responsible party, who brought R1 to the urgency care office visit where a physical exam was performed describing scrapes, bruises, and extreme itching with several cuts mainly on right arm, bruises on their lower arms, hands, and wrists; lacerations and skin tears that appear to be from fingernails. Hydroxyzine 25mg tablets were prescribed to R1 for itching/anxiety. 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 conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Jan 7, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jan 8, 2025

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional & social functioning & that appropriate assistance is provided when such observation reveals unmet needs...& brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement has not been met as evidence by: Based on interviews and record review the licensee failed to seek medical attention after observing R1’s injury, which poses an immediate risk to the health and safety of the residents in care.the state’s words, verbatim · CDSS document, Jan 7, 2025

Plan of correction: Administrator to submit a statement that they understand regulation 87466 and shall be in future compliance ensuring residents are regularly observed for changes as the Plan of Correction (POC) by due date to clear the citation.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Health and Safety inspection and met with Camille Brown, Administrator. This full dementia facility has 45 residents in care. Upon arrival on 8/20/2024 at 10:00 AM LPA toured facility and observed 11 staff, facility to be clean and at a comfortable temperature, activities were being conducted in the dining room and there was enough food per regulation. No immediate concerns noted. There were no deficiencies cited during today’s visit.the state’s words, verbatim · CDSS document, Aug 20, 2024

Type of visit: Required - 1 Year

License Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required - 1 Year inspection of the facility. LPA was welcomed by and met with Director of Sales Lisa Lomeli who is designee as Administrator was unavailable for today’s visit. This senior living community is a full memory care facility. There is a total of 45 residents with 10 residents currently on Hospice. LPA toured the facility on 04/12/2023 at 8:15 AM with Director of Health Services (DHS) Lupe Villa-Guerrero and Director of Environmental Services Kyle Manford; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The tour of the facility included nine resident apartments, activity rooms, Library, music room, dining rooms, kitchen and outdoor patios & courtyard. Facility serves residents with dementia and has special care plan of operation and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. Food was found to be handled and stored in a safe manner. Facility kitchen has a binder with all resident’s names and their needs. Menu is posted. Food is available for residents any time of the day. Fire Extinguisher was found to be last charged on 12/22/2023 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected by a vender with the last inspection being conducted on 12/22/2023. LPA observed 4 out of 4 Carbon monoxide detectors that were found to be operational during the visit. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between 109.4 degrees F and 117.6 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 9 of 9 resident’s bathrooms while touring facility. Bathrooms contained necessary grab bars and showers contained non-slip floor/mats. Toxins are stored in a locked housekeeping room. Continued on LIC809-C There was a supply of cleaners, hygiene products and paper products available for residents; although LPA and DHS observed shampoo, conditioner, lotions, spray cans of air freshener, ointments, mouthwash with alcohol, sewing needle & nail polish in multiple resident rooms & bathrooms (see pics) per regulation 87705(f)(2) Care of persons with dementia, such items as alcohol, toxic substances, and disinfectants shall be stored inaccessible to residents with dementia (see LIC809-D). DHS removed items during tour. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Beds were outfitted with mattress pads as required by Title 22 Regulations # 87307 on 4/12/2024 at 9:00AM. A sample review of five resident & five staff records as well as three resident’s medications was conducted. LPA reviewed resident’s files at 11:15 AM on 4/12/2024 and learned that 5 out of 5 residents have an updated reappraisal/needs & care plan on file as well as medical assessments at this time as required by Title 22 Regulation. Medications were centrally stored in two locked medication carts in the facility medication room. The Medications of 3 out of 3 residents were found to be given according to physicians’ directions on 4/12/2024 at 10:00 AM. Centrally Stored Medication Record (CSMR) of 3 out of 3 residents were found to be complete and accurate. LPA conducted a sample reviewed of staff records at 12:30 PM on 4/12/2024 and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received the additional training requirements as per Title 22 Regulations and H&S Code. LPA was presented with proof of CPR & 1st Aid certification for required staff. Disaster Drills have been conducted monthly in different shifts with the last one being conducted on 3/29/2024. Director of Environmental Services informed in case of disaster and power goes out, facility has a permanent generator that self tests once a week. Camille Brown Administrator Certificate # 6037875740 expires on 7/24/2024. Appeal of Rights Given. Continue on LIC809-C The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. LPA Hansen is requesting Licensee to update the following documents by 5/7/2024: LIC 308 Designated -if changes LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan – if changes LIC 9020 Register of Facility Client’s/Resident’s Copy of Administrator Certificate Copy of Certificate of Liability Insurancethe state’s words, verbatim · CDSS document, Apr 12, 2024

Allegation investigated: Staff did not prevent an outbreak of scabies. Staff not prevent outbreak of covid.

Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. This investigation included three site visits to the facility; a review of pertinent documents; as well as statements taken from staff and witnesses. The following determinations are made: In December of 2023, facility had several cases of Covid; Facility management followed appropriate protocols and made reasonable attempts to keep Covid positive residents isolated; There exists differing opinions as to whether or not the facility had an outbreak of scabies in the Fall of last year; Ten resident files were selected on a random basis and reviewed for indications of scabies; Ten of ten files were negative for any indications of scabies diagnosis; several files indicated various skin issues or rashes but none were identified as scabies. Although the complaint allegations may be true or valid, based upon statements and reviewed documents, there is not a preponderance of evidence to prove, or disprove, the allegations. Therefore, the allegations are UNSUBSTANTIATED. Report left. No citations issued today. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 22, 2024 · control 21-AS-20240109100757

Allegation investigated: Insufficient staffing to meet residents care needs Staff do not have adequate training

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Administrator, Camille Brown. Insufficient staffing to meet residents care needs – Complainant alleges due to lack of staffing, tasks such as laundry are not being completed as scheduled, leaving residents without clean clothing and unable to assist residents with activities of daily living (ADL)’s, toitleting & hygiene services. LPA’s record review & interview with administrator revealed facility has 6 med techs & 23 caregivers. LPA was informed one of the washing machines has had some operating issues and the facility is addressing repairs. Administrator informed LPA of alternative plan if there is a backlog of laundry to ensure it is completed timely. Interviews were conducted with (5) staff who were consistent in informing LPA residents’ rooms are cleaned the same day as their laundry day. Three housekeepers work 5 days a week washing laundry and caregivers will help if requested. LPA obtained staff schedule to confirm sufficient staffing. Continue on LIC9099-C Unsubstantiated On morning of 11/2/2023 while touring facility LPA observed identified resident (R1) to be well dressed in good hygiene and walking hallways with staff. On early afternoon of 11/13/2023 while at facility LPA observed R1 sitting in hallway chair fully dressed in clean cloths and groomed. LPA observed R1’s closet having plenty of clean clothes (pants, shirts, undergarments able to be worn (see pics)) along with laundry basket of clothes and bed linen. Based on LPAs interviews, record review, and observations, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, Insufficient staffing to meet residents care needs, did or did not occur, therefore the allegation is Unsubstantiated. Staff do not have adequate training – Complainant alleges staff are not adequately trained due to sending residents out to the hospital several times for various behaviors and incidents when they should be able to handle behavioral issues instead of sending out. LPA obtained training records of 5 staff that revealed staff have required trainings per regulation including Dementia Care training. Based on LPAs record review resident (R1) was sent out of the facility on two occasions due to change of condition and returned with diagnosis of UTI. LPA did not obtain any additional information that facility staff are not adequately trained and/or sending residents out of the building for unjust reason. Therefore, the allegation is Unsubstantiated. 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 allegations are Unsubstantiated.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 21-AS-20231024151946

Allegation investigated: Residents' needs are not being met Facility is not handling resident's incontinence care needs

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Administrator, Camille Brown & Lupe Villa-Guerrero, Director of Health Services. Residents' needs are not being met – Complainant alleges when resident (R1) moved into facility they forgot their toothbrush and toothpaste. Family realized this two weeks later and asked staff how they handle this situation, staff allegedly replied it is family’s responsibility to bring these items and if the resident didn’t have them, staff don’t brush their teeth. On 8/17/2023 LPA was informed by Director of Health Services Guadalupe Villa-Guerrero that residents are suppose to bring their own hygiene products but if they don’t, the facility has back up supplies and will provide to the residents and then inform the family of the need. LPA’s file review of care plan indicates R1 only requires stand by assistant with grooming. Continue on LI9099-C Unsubstantiated LPA’s interview with R1 and medical professional (physical therapist) revealed, R1 brushes their own teeth regularly. Although the allegation, Residents’ needs are not being met, 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. Facility is not handling resident's incontinence care needs- Complainant alleges R2 was yelling roommate had defecated and for at least two hours staff did not come to help. Complainant also alleges when staff came by was told they didn’t have time to help. When LPA conducted interview with reporting party, information regarding time frame was not consistent with complaint and was unable to get any specific times or staff names. LPA conducted record reviews and both R2 & R3 have diagnoses of dementia. LPA interviewed R2 who could not recall the incident. Staff interview indicated that R3 has not had any specific incidences of incontinence problems and indicated that all residents are checked every two hours and assisted with incontinence care, if needed. Although the allegation, Facility is not handling resident’s incontinence care needs, 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 Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 13, 2023 · control 21-AS-20230815133258

Allegation investigated: Resident sustained a fracture due to lack of care from staff

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Administrator, Camille Brown. Resident sustained a fracture due to lack of care from staff – Complainant alleges resident (R1) sustained a fractured shoulder due to staff not picking up bathroom rug and R1 tripped over it in the middle of the night. LPA’s interview with staff (S1) & S2 revealed S1 was conducting routine, two-hour rounds of facility residents at approximately 5 AM. This was S1’s second round of R1’s room in less than 2 hours. R1 usually has the lights on, although they were not so S1 turned them on when seeing R1 was walking back to the bed from using the bathroom. S1 greeted R1 and R1 began to turn around by the bed and lost footing and went down hitting their shoulder. S1 went to R1 and called S2 to come help and assess. Continue on LIC9099-C Unfounded 911 was called and from the time of the fall until after paramedics left, S1 stayed with R1. S1 indicated R1 informed the paramedics of shoulder pain. LPA obtained paramedics report dated 9/25/2023 at 5:22 am that indicated fall was witnessed and there was good range of motion, as well R1 declined transport to hospital and had POLST on file with comfort measures only. LPA’s Interview with S2 informed, although the paramedics helped R1 back into bed, the facility does not need assistance helping residents who fall in their rooms back to bed. LPA interviewed the Director of Health Services who confirmed the facility used to call 911 for lift assists with larger residents but discontinued the practice years ago. The investigation revealed facility incident report dated 10-2-2023 indicates the fall was unwitnessed by S2, but further investigation revealed it was witnessed by S1 who observed R1 turning at their bedside and falling. Therefore, the allegation Resident sustained a fracture due to lack of care from staff is Unfounded. This agency has investigated the complaint and has found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.the state’s words, verbatim · CDSS document, Nov 2, 2023 · control 21-AS-20231016084025