Murrieta Gardens

Allegation investigated: Unlawful eviction

Licensing Program Analyst (LPA) Ivashia Wright made an unannounced visit to initiate the investigation regarding the allegation listed above. LPA was granted entry and met with Administrator Kylee Carter and explained the purpose of the visit. LPA conducted a tour of the facility, conducted interviews with staff, witnesses, and requested copies of pertinent documentation. In regard to the unlawful eviction, it was reported that R1 was set to be discharged from the facility on 6/29/2026. Interview with Administrator Kylee revealed R1 has not been issued a eviction notice. Kylee reported R1 has not left the facility since admission. Administrator Kylee reported Temecula Valley Hospital made an arragement to pay for 1 month of services for R1 beginning 5/29/26 and ending 6/28/26. Information obtained from interview with R1's Responsible party corroborated that the facility did not issue a eviction notice to R1 and R1 still resides at the facility. R1's responsible party reported they were unsure how R1's rent would be paid after 6/28/26. Continued on LIC 9099-C... Unfounded R1's Responsible party reported they reached out to Adult Protection Service (APS) for assistance with getting R1's Assisted Living Waiver (ALW) approved quickly to assist with R1's rent. R1's Responsible party reported that as of 7/1/26 R1 was successfully enrolled in the ALW program. LPA Wright further verified this by obtaining a copy of ALW documents provided by APS. Based on staff interviews, witness interview, and R1's files allegations that R1 was unlawfully evicted has been deemed unfounded. This means that the allegation is false, could not have happened, or is without a reasonable basis. An exit interview was conducted and a copy of this report was discussed and provided to Administrator Kylee Carter.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 18-AS-20260628181251

Allegation investigated: Facility staff mismanaged Resident 1's medication

On 04/28/2026, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility to investigate the allegation listed above. LPA met with Administrator Kylee Carter who was informed of the purpose of the visit. LPA toured the facility with Administrator Carter, conducted interviews, and obtained copies of pertinent documentation. Regarding the allegation, “Facility staff mismanaged Resident 1's medication” it was reported that on 01/16/2026, Resident 1 (R1) received a 30-day refill supply of Medication 1 (M1) to be dispensed every night at bedtime which required to be refilled again on or before 02/16/2026. It was alleged that the facility staff did not notify R1’s responsible person that M1 had depleted which resulted in R1 not receiving M1 until mid March of 2026. It was further alleged that on 01/20/2026, R1 received a 90-day supply of Medication 2 (M2) to be administered every evening, which required to be refilled on or by 04/20/2026. However, it was reported that a physical audit of R1’s medications was conducted on 04/18/2026 and revealed there were approximately 20 tablets leftover of M2 in the medication bottle. Substantiated Administrator Carter was interviewed and reported that medication technicians/wellness director are trained and required to contact a resident’s responsible person approximately 7-14 days in advance to request a medication refill prior to a medication depleting to allow sufficient time for the refill to be delivered to the facility promptly. Administrator was unable to locate any record to prove that R1’s responsible person was contacted to request a refill for M1 on or around February of 2026. LPA reviewed R1’s physician’s report dated 12/10/2024 documenting R1 exhibits memory loss and requires medication management. LPA reviewed R1’s Resident Service Plan listing their date of admission as 02/27/2025 also noting R1 requires medication management. LPA reviewed R1’s physician’s order for M1 dated 12/15/2025 and M2 dated 01/20/2026. LPA reviewed R1’s Centrally Stored Medication and Destruction Record (CSMDR) documenting the facility received 30 tablets of M1 on 01/13/2026 followed by 90 tablets on 03/13/2026. However, the CSMDR does not note the facility received a refill for M1 on or before 02/12/2026. The CSDMR also notes the facility received 90 tablets of R1’s M2 on 01/20/2026. LPA reviewed R1’s MAR for February of 2026 which documents R1 received M1 and M2 as prescribed during the entire month. LPA also reviewed R1’s MAR for March of 2026 and noted M1 and M2 have 14 dates where the staff initials are circled in the section that is used to document whether the medications were administered. Administrator Carter explained that circled staff initials in the MAR indicate the medication was not given due to reasons such as the resident being out of the facility or the facility awaiting medication delivery. LPA reviewed the R1’s MAR exception which documents the reason for not dispensing the medication on the 14 dates as, “Awaiting Delivery”. Administrator Carter reported, “Awaiting Delivery” refers to facility staff waiting for medications to be delivered to the facility. However, the CSMDR notes the facility received 90 tablets of R1’s M2 on 01/20/2026 which did not require to be refilled until 04/20/2026. LPA also reviewed a photograph dated 04/18/2026 of R1’s M2 that contained at least 20 tablets in the medication bottle. There is no record or report that R1 received physician orders to discontinue M1 or M2 during the time the MAR for March of 2026 notes R1 did not receive the medication. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report, Confidential Names list (LIC 811) and Appeal Rights were reviewed and provided to Administrator Carter.the state’s words, verbatim · CDSS document, Apr 28, 2026 · control 18-AS-20260420151242

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 8, 2026

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and records conducted, the facility mismanaged R1's medications. This poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Apr 28, 2026

Plan of correction: Administrator reported she will develop a "Medication Refill Request Log" to ensure medication refills are requested timely. Administrator reported she will also conduct an in-service staff training regarding proper medication management and documentation. POC to be emailed to LPA by cob on 05/08/2026.

Allegation investigated: Staff did not prevent a resident from sustaining a fracture while in care

On 3/30/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering the investigative findings into the allegation listed above. LPA Flores met with Administrator Kylee Carter and explained the purpose of the visit. The investigation was conducted by the Investigation Branch and is summarized as follows: Information received alleged staff did not prevent Resident #1 (R1) from sustaining a fracture while in care. Staff interviews revealed that R1 is known to be a fall risk but primarily uses a wheelchair. Administrator reports R1 exhibited signs of pneumonia and R1’s responsible person requested R1 to be transferred to the doctors for evaluation. During that hospital visit, a chest x-ray was taken of R1. Administrator reported that the X-Ray revealed multiple rib fractures. (Continue to LIC9099C) Unsubstantiated (Continuation from LIC9099) Administrator reported that the hospital staff reviewing the x-ray elevated their concerns when it was later discovered that prior chest x-rays showed the rib fractures. A records review was conducted of the facility’s Unusual Incident Reports. A report dated 6/29/2025 documented an unwitnessed fall in which R1 was found seated on the floor, at the base of the couch. She was transported to the hospital for evaluation, where it was confirmed that no injuries were sustained. A report dated 7/20/2025 documented that R1 had exhibited signs of pneumonia and was transported to the hospital by their responsible. This incident is the direct subject of the current investigation. Other than these two reports, no additional incidents involving R1 have been reported. Interview with R1 report that R1 slipped off the couch earlier that year but does not recall sustaining any injuries. An interview with R1 and their responsible person report that R1 was in a major car accident in the 1990’s causing R1 to sustain multiple rib fractures. R1 responsible person reports that the prior fracture was still shown in the x-ray, but the area of the fractures is healed. Interview with R1 confirmed that there is no residing pain from the prior rib fractures and does not recall the last time when R1 experienced pain in that area. Attempts to interview Witness #1 (W1) were unsuccessful. Additional information received document “Per provider, radiologist re-reviewed imaging from previous visit and the rib fractures were present at the time, just didn’t get notated. Plan for DC back to Murrieta Gardens”. Based on interviews and records review, the allegation of “staff did not prevent a resident from sustaining a fracture while in care” is deemed unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means 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 allegations are unsubstantiated at this time. An exit interview was conducted where this report was discussed and provided to Administrator.the state’s words, verbatim · CDSS document, Mar 30, 2026 · control 18-AS-20250721211454

Allegation investigated: Staff did not prevent one resident from hitting another resident

On 3/3/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of launching the complaint investigation into the allegation listed above. LPA met with Administrator Kylee Carter and explained the purpose of the visit. Information received alleged staff did not prevent Resident #2 (R2) from hitting Resident #1 (R1). Interview with Staff #1 (S1) reported that R1 and R2 were sitting on the couch in the main room. S1 was standing in close proximity to the resident when S1 overheard noises. S1 glanced up and observed R1 and R2 grabbed onto each other’s forearms and were tugging back and forth. As S1 approached the residents, S1 observed R2 release their right hand from R1’s left forearm and began striking R1 on the left side of R1’s head with an open hand. S1 reported that they placed their body in between both residents to separate the residents. S1 further reported that Staff #2 (S2) overheard the commotion and redirected R1 to a safer area. (Continue to LIC9099C...) Unsubstantiated (Continuation from LIC9099) Interview with S2 reported that S2 was standing near the entryway of the main room when S2 overheard a loud slapping noise. S2 reportedly rushed towards the noise and observed R2 with their hand raised and began hitting R1 with an open hand. S2 reported observing S1 separating the resident and S2 assisted with redirecting R1 away from R2. After the residents were separated, staff reported that S2 contacted emergency personnel as R1’s left side of the forehead had light bleeding. Staff report that R1 had prior stitching due to an unrelated incident. As a result of the physical altercation, a stitch on R1’s forehead was removed. Staff interviews reported that S2 contacted emergency personnel. Upon emergency personnel’s arrival, R1 was transported to the hospital due to the stitch being removed from R1’s head. Interviews with staff and Witness #1 (W1) reported that R2 was not observed to have sustained any injuries. Staff interviews reported that R2 does not have a history being physically or verbally aggressive towards residents and does not require constant care and supervision. LPA attempted to interview R1 and R2 but due to cognitive abilities, the interview attempts were unsuccessful. A review of R2’s care plan details that R2 requires checks at more frequent interval and may exhibit physically or verbally aggressive behaviors. A review of R1’s care plan detailed that R1 requires checks a regular intervals and has a history of aggressive behaviors in prior facilities. Records review conducted for R1 and R2 does not report either residents requiring constant care and supervision. Interview with Administrator explained that regular checks are conducted every two hours and frequent checks are conducted every hour. LPA was informed that the facility does not maintain surveillance cameras in that location of the building. Due to insufficient evidence, the allegation of staff did not prevent one resident from hitting another resident is deemed UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means although the allegation may have happened and/or is valid, there is not a preponderance of evidence to prove the allegation did or did not occur. An exit interview was conducted, and a copy of this report was provided to Administrator Kylee Carter.the state’s words, verbatim · CDSS document, Mar 3, 2026 · control 18-AS-20260225084111

Type of visit: Required - 1 Year

On 10/6/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced 1-year required visit. LPA met with Administrator, Kylee Carter, and explained to Kylee the purpose of the visit. Administrator Kylee granted LPA entry to the memory care facility. During the visit, LPA conducted a tour of the facility and observed the following: The facility is a two-story structure which consist of (61) sixty-one units. The facility is licensed for (126) one hundred and twenty-six non-ambulatory residents to which (20) twenty may be bedridden on the first level only. The Licensee was observed to be operating with their scope. LPA observed kitchen to be clean and free of rubbish. Food is stored in a safe and healthful manner by ensuring all food items were properly dated and free of mold. Utensils and dishware are sufficient for the approved capacity. LPA observed food supply met the requirement for a (2) two-day supply of perishable food and (7) seven-day supply of non-perishable food. Sharps are secured in the locked kitchen and inaccessible to the residents. During the visit, LPA observed food staff preparing food. All persons engaging in food preparation and service were observed to maintain personal hygiene and proper sanitation practices to protect the food from contamination. Indoor/outdoor passageways were observed to be free of obstruction. Fire extinguisher is charged and up to date. Resident bedrooms were observed to be equipped with the required bedding, furniture, seating, and functional lighting. Resident bathrooms were observed to have working toilet, sinks, and were equipped with a grab bar in the shower and toilet areas.LPA observed laundry room to be clean and inaccessible to residents as it housed cleaning supplies. Washing machine and dryer were observed to be in good repair. LPA observed sufficient amount of extra towels and linen located in the laundry room. (Continue to LIC809C...) (Continuation from LIC809C...) The facility exits were equipped with permitted egress devices to ensure resident safety. All outdoor pathways were free of obstructions. No bodies of water were observed. Licensee promotes socialization by organizing (3) three or more planned activities to encourage physical activities, interactive games between residents, and host socializing events. The facility maintains sufficient space to host these interactive planned activities. A fire alarm service test report was conducted on 04/23/2025 by Murrieta Fire and Rescue. The report indicated the fire alarm system to be in good repair. Per Administrator, there are no firearms and/or ammunition on the premises. LPA conducted records review of (7) seven residents. Resident records included but not limited to preplacement appraisals, assessments, medical and dental, needs and services plans, physician reports, personal rights, signed telecommunication device notifications, property and valuables, and admission agreements. LPA conducted (3) three staff records. Staff records included but not limited to valid CPR/First-aid Certification, health screenings, valid TB test, criminal record clearance, personnel record. job application, and training's pertaining to job functions. An exit interview was conducted and a copy of this report will be provided to Administrator, Kylee Carter.the state’s words, verbatim · CDSS document, Oct 6, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Armando Perez, conducted an announced visit for the purpose of conducting the pre licensing inspection. LPA met with Applicant, Brittany Kavenaugh and Administrator Kylee Carter for the visit. The applicant is seeking a change in ownership with residents in care for a residential care facility for the elderly, ages 60 and up. The facility is a two-story building with a capacity for 126 residents with 20 bedridden approved on the first floor. On 07/10/24 the Murrieta Fire and Rescue approved a fire clearance. LPA toured the facility with the applicant and observed the following: LPA inspected a sample of resident bedrooms and bathrooms. Resident bedrooms have the required bedding and furniture; such as clean mattresses, night stands, storage space, and sufficient lighting. Room temperatures were comfortable for residents in care. LPA inspected a sample of resident bathrooms; the bathroom appliances were operating in safe and sanitary conditions. Showers contained non-slip surface and access to grab bars in the showers and next to toilets. LPA measured the hot water temperature in the sampled bathrooms and measured within regulation. Bedrooms were equipped with a pull cord system to notify staff of any emergencies. LPA toured the kitchen and dining area. LPA observed two refrigerators and a freezer set at required temperatures. The facility kitchen was stocked with sufficient food to meet the required 2-day supply of perishable and 7-day supply of non-perishable food items. Access to the kitchen remains locked when not occupied with staff. Knives and sharps are stored in a designated area next to the sink. The facility had a menu posted and available for review. Dishes, glasses, and utensils were in good condition. LPA observed an activity room, a media room and a library room located on the first floor and open to residents. The facility has a centralized storage area located in the second floor where resident files and medications are to be stored, locked, and inaccessible to the residents in care. The facility has a designated area on the first floor for staff files. LPA verified the applicants Administrator Certification, with an expiration date of February 22, 2026 and CPR certification, with the expiration date of January 19, 2026. LPA observed required postings including the visitation polices, emergency/disaster plans, complaint procedures, employee rights, personal rights and the Long-Term Care Ombudsman poster. The facility has an emergency disaster plan and approved infection control training plan on file. Facility contains emergency supplies and first aid kits with the required items. The facility has working telephone for client use. LPA observed several smoke detectors and carbon monoxide alarms throughout the facility. The buildings and grounds were free from hazards. Outdoor and indoor passageways were kept free of obstruction. No bodies of water or firearms are being kept in the facility. LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA determined the facility meets the operational requirements for licensure. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to applicant Brittany Kavenaugh and Administrator Kylee Carter.the state’s words, verbatim · CDSS document, Sep 24, 2024