Newport Mesa Senior Living

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20260909100358. LPA was greeted and granted entry into the facility and explained the reason for the visit. Regional Director Sheila Bottinelli and Memory Care Director Melissa Domingo arrived during the visit. During the course of the complaint visit, LPA observed facility failed to notify the department via "Unusual Incident Report" of Resident 1's fall and send out to the emergency room. Based on the observations made during today's visit, a deficiency is being cited on the attached LIC809-D page. An exit interview was conducted and a copy of the report and appeal rights were provided to the facility at time of visit.the state’s words, verbatim · CDSS document, Sep 17, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Sep 24, 2026

Each licensee shall furnish to the licensing agency such reports as the Department may require.. within seven day.. This report shall include the resident's name..any incident which threatens the welfare, safety or health of any resident..This req is not met as evidenced by: Based on record review, Licensee failed to ensure the department was notified of R1's fall and send out to the hospital which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2026

Plan of correction: Licensee to report the incident in writing to LPA by POC due date

Type of visit: Case Management - Annual Continuation

On June 16, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Annual Continuation inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Melvin Galloway was present and assisted on today's visit. During today's visit, LPA reviewed four staff files. All staff are background cleared and associated to the facility. However, LPA observed that Staff #3 (S3) did not have sufficient annual training hours for the year of 2025. Per Health & Safety Code 1569.625(b)(2), all direct care staff shall receive twenty hours of annual training of which consist of eight hours in dementia care, and four hours shall be in postural supports, restricted health conditions, and hospice care. LPA observed that S3 only received one hour of training in dementia care in 2025, and did not receive any training in postural supports, restricted health conditions, or hospice care. Based on the observations made during today's visit, a deficiency is being cited on the attached LIC809-D page. An exit interview was conducted with Executive Director Melvin Galloway. A copy of the report and appeal rights were provided to the facility at time of visit.the state’s words, verbatim · CDSS document, Jun 16, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: Jun 30, 2026

1569.625 Staff training; legislative findings; contents: (b)(2) .. training requirements shall also include .. 20 hours annually, eight hours ... shall be dementia care training.. and four hours .. shall be specific to postural supports, restricted health conditions, and hospice care... This requirement is not evidenced by: Based on records reviewed, the Licensee did not ensure that S3 received sufficent training for 2025 since S3 had 1 hour of training in dementia care & had 0 hours in postural supports, restricted health conditions, and hospice care. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 16, 2026

Plan of correction: The Executive Director stated that he will have S3 complete the required annual training for the year of 2025. The Executive Director agreed to provide LPA proof of completed training for S3 via email or fax by POC due date.

Allegation investigated: Staff did not ensure the residents were administered their medication

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. It was alleged staff do not ensure the residents were administered their medication. LPA conducted interviews with staff. LPA reviewed records obtained. The investigation determined as follows: Regarding the allegation staff did not ensure the residents were administered their medication, it was reported medications are not being administered per physician's orders. Interviews with four out of eleven staff stated on December 7, 2025, medications were given to residents late because there was no staff available to administer resident medications. Resident 2 (R2) called Costa Mesa PD to report no one provided their medications. Costa Mesa PD arrived at the facility. The police officer called Staff 1 (S1) to have them return to the facility to assist with administrating medications. Substantiated Interview with S1 stated they were called by a police officer to make them aware there was no one available to administer medications. S1 stated they arrived at the facility at 8:45pm that day and finished passing medications at 9:30pm. One out of the remaining seven staff stated they have observed medications on the floor during their shifts. One out of the remaining six staff stated they have observed medications in residents' hands from a previous medication pass. One out of the remaining five staff stated there are no med techs that work on weekends. Two out of the remaining 4 staff stated they have not observed residents not given their medications. One out of the two remaining staff stated they assist residents with medications as prescribed. The remaining staff did not add anything relevant to the allegation. LPA attempted to interview R2 but was unable to qualify for the interview. LPA reviewed a copy of the Costa Mesa PD log for the incident which stated "Per caregiver onsite the med tech did not respond like they were supposed to at 1400 hours no patients recieved memory care medications she tried calling the managers but no answer was able to reach employee (S1) who said would respond with 30 min eta and give medication per (S1) this was a scheduling error on managers behalf and has not happened in the past 5 years of his employment [12/07/25 18:28:49 Unit:322]". LPA conducted medication audit for R2 during the initial visit on December 16, 2025 which revealed seven medications that were marked as administered in the facility's electronic medication administration record (eMar) were physically still present in R2's medication bubble packs for multiple days. Staff could not account for discrepancies. LPA documented the seven medications and eMar via photographs. Based on interviews conducted, observations, and record review, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6), is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of the report was left with the facility representative along with appeal rights. Two out of the remaining eight staff stated if a resident falls, they will inform the supervisor. One out of the remaining six staff stated if a resident falls and is injured, they will call 911 for assistance. The remaining five staff did not add anything relevant to the allegation. Record review revealed R1 was admitted to the facility on August 27, 2025. R1's medical assessment dated August 28, 2025 indicates R1 has a skin condition of trauma to their left forearm and wrist. Resident assessment dated October 2, 2025 indicated resident was receiving wound/skin care. R1 was admitted to a skilled nursing facility (SNF) on December 2, 2025. The admission record from the SNF does not indicate any diagnosis of skin tears or trauma to the left arm. However, there is a diagnosis of pain in the left arm. LPA was unable to qualify R1 for an interview during the initial visit on December 16, 2025. LPA did observe bandages on R1's left arm. LPA did not observe any bleeding. Regarding the allegation staff are administering nonprescribed medication, it was reported staff is administering melatonin to residents to have them go to sleep without a prescription. Four out of eleven staff stated they never observed a house stock of melatonin in the medication room. One out of the remaining seven staff stated there was a bottle of melatonin in the medication room, but it was prescribed for one resident and not given to others. One out of the remaining six staff stated they recall seeing a bottle of melatonin in the medication room. The remaining five staff did not add anything relevant to the allegation. LPA did not observe any bottle of melatonin in the medication room during the initial visit on December 16, 2025. Regarding the allegation staff left residents in soiled diapers for an extended period of time, it was reported residents are not being changed overnight and are left soiled by the nocturnal (NOC) shift. Interviews with seven out of eleven staff stated they have not observed residents soiled for an extended period of time. Two out of those seven stated they have been informed by other staff of residents being left soiled from the previous shift. One out of the remaining four staff stated they have observed residents left soiled for an extended period of time. One out of the remaining three staff stated if they were to witness a resident soiled for an extended period of time, they would inform the supervisor. One out of the remaining two staff stated it is the lack of staffing that would cause residents to be soiled for an extended period of time. The remaining staff did not add anything relevant to the allegation. LPA did not observe any residents soiled during the initial visit on December 16, 2025. Based on interviews, observations and record review, the above allegations are therefore deemed unsubstantiated meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of the report was left with the facility representative.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 22-AS-20251208162553

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 5, 2026

Incidental Medical and Dental Care The licensee shall assist residents with self-administered medications as needed. The requirement is not met as evidenced by: Medications for all residents were administered late due to no qualified staff being available on the evening of December 7, 2025. In addition, medication audit for R2 indicates seven medications were not given as prescribed which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 4, 2026

Plan of correction: Memory Care Director stated daily and weekly medication audits have been put in place. All current med techs have received training from a license pharmacist. Memory Care Director to send proof to LPA by POC due date.

Type of visit: Required - 1 Year

On June 4, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Melvin Galloway was present and assisted on today's visit. LPA observed that Melvin Galloway has a valid Administrator certificate which expires on August 13, 2027. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for forty non-ambulatory residents, of which fifteen may be bedridden, and has a hospice waiver for fifteen. The facility consist of two buildings, one of which is a two story building. The second story of the building is for staff use only and is not accessible to residents in care. The facility consist of twenty two resident bedrooms, eight shared resident bathrooms, living areas, dining room/activities room, a kitchen, storage rooms, laundry rooms, and staff offices. On today's visit, there were nineteen residents in care. LPA, accompanied by the ED, conducted a tour of the interior portions of the facility. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected eight resident bedrooms, which consisted of bedrooms in each building. LPA observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA tested the signal system located in the resident bedrooms which tested operational. LPA inspected the eight shared resident bathrooms which were observed to be free of any hazards. LPA observed bathrooms to be equipped with grab bars. Faucets and toilets were operational. The hot water temperature measured between 108.1 and 113.1 degrees Fahrenheit. LPA inspected the facility's kitchen area and observed it to be clean. CONTINUED ON LIC809-C LPA observed the facility has a two day perishable and a seven day non-perishable food supply on hand. LPA observed kitchen knives and sharps to be stored inaccessible to residents in care. LPA observed kitchen appliances to be clean and operational. LPA observed the facility has a three day emergency food and water supplied stored in the kitchen pantry. LPA observed chemicals and toxins to be stored in locked laundry rooms. LPA observed multiple fire extinguishers to be mounted on the walls in both buildings. Fire extinguishers were observed to be charged and serviced as of December 2, 2025. LPA observed the facility passed their most recent fire inspection visit conducted on May 14, 2026, which consisted of testing the smoke detectors, carbon monoxide detectors, and fire sprinklers. LPA observed the facility conducted their most recent emergency disaster drill on May 14, 2026. LPA observed centrally stored medications are kept in a locked medication room located in the southern building. LPA observed a first aid kits to be stored in the medication room and it had all the required components. LPA inspected all other common areas such as living areas, dining room/activities rooms, storage rooms, laundry rooms, staff offices, and observed them to be free of any hazards. LPA, accompanied by the ED, conducted a tour of the exterior portion of the facility. LPA observed the exterior to be free of any hazards or obstructions. LPA observed shaded outdoor seating areas with furniture for resident use. LPA tested the one delayed egress door of the facility which tested operational. There are no bodies of water on the premises. LPA reviewed eight resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed residents’ medication and medication administration records. Due to time constraints, LPA will conduct a follow up visit to complete the annual inspection. An exit interview was conducted with Executive Director Melvin Galloway and a copy of the report was provided to the facility at time of visit.the state’s words, verbatim · CDSS document, Jun 4, 2026

Type of visit: Case Management - Health Checks

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Fred Arias for the purpose of a health and safety check. LPA met with Executive Director (AD) Melvin Galloway and Memory Care Director Melissa Domingo and explained the purpose of the inspection. During the inspection, LPA and AD toured the facility. LPA conducted health and safety checks on residents and confirmed they were doing well and observed no health and safety issues. LPA observed the facility clean and organized. LPA observed utility services operational. LPA requested and reviewed copies of resident roster, staff roster, and resident files. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, May 20, 2026

Type of visit: POC

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit for the purpose of conducting a Plan of Corrections visit for a deficiency issued on October 21, 2025 during a case management visit. LPA was greeted and granted entry by staff. LPA discussed the purpose of the inspection with Executive Director (ED) Melvin Galloway. LPA toured the facility to check the deficiency had been corrected with ED. LPA along ED tested the egress door by the front entrance. LPA observed egress door to be fully operational. Based on LPA's observation on today's visit, the Plan of Correction has been fulfilled thus clearing the deficiency cited CCR 87505(d). An exit interview was conducted and a copy of this report was provided to the facility representative.the state’s words, verbatim · CDSS document, May 20, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced case management visit to the facility to conduct a health and safety check for an incident that was reported to the Regional Office. LPA explained reason for visit and was greeted by staff on duty. On October 13, 2025, the Regional Office received an incident report of elopement with the incident occurring for October 05, 2025 for resident 1 (R1). R1 exited the facility at approximately 10:34am on that day. Staff was made aware R1 was not at the facility and initiated search and safety protocols at 11:30am. R1 was located by local law enforcement and brought back to the facility at approximately 3:30pm the same day. The facility's main entry and exit door is in the process of repair and has partial functionality. Temporary measures haven taken place to alert staff when the door is open including an audible alarm that will alert every time the door is open regardless if the door is armed. LPA tested the egress function and it is operational. The facility held in-service training for staff on September 9, 2025, October 3, 2025, and October 6, 2025 on updated protocols for elopements. Facility provided updated elopement policy along with R1's records to LPA. Executive Director Melvin Galloway stated the facility will complete an ongoing remodel by mid November which includes replacing the main door's electronics to restore full functionality. LPA toured the facility and observed no health or safety concerns. Based on the observations made during today’s visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.the state’s words, verbatim · CDSS document, Oct 21, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(d) · Plan of correction due date: Oct 22, 2025

87705(d) Care of Persons with Dementia The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement... The requirement was not met as evidenced by: R1 was able to exit the facility due to a malfunctioning door alarm which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: ED stated new electronics for egress will be installed and functioning by POC due date. LPA will validate on a future visit.

Type of visit: POC

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit for the purpose of conducting a Plan of Corrections visit for deficiencies issued on August 5, 2025 during a plan of correction visit. LPA was greeted and granted entry by staff. LPA discussed the purpose of the inspection with staff Keatlen Ballanes. LPA toured the facility to check the deficiencies had been corrected with staff. LPA along with staff entered four rooms randomly. LPA observed four out of four rooms with a signal system installed. LPA measured temperature of bathroom sink next to room 8 in the Winter Cottage Building. Temperature in the bathroom measured at 110.8 degrees F. Based on LPA's observation on today's visit, the Plan of Corrections has been fulfilled by the assigned POC due dates of August 6, 2025 and August 12, 2025, thus clearing the Type A deficiency CCR 87303(e)(2) and the Type B deficiency CCR 87303(i). An exit interview was conducted and a copy of this report was provided to the facility representative.the state’s words, verbatim · CDSS document, Aug 19, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit for the purpose of conducting a Plan of Corrections Inspection for deficiencies issued on 05/21/2025 during the required annual inspection. LPA was greeted and granted entry by staff and discussed the purpose of the visit. LPA toured the facility to check the deficiencies have been corrected with staff. Water temperature in the bathroom by room 8 measured 126.5 degrees F, higher than previous reading of 89.9 degrees F during the annual inspection. LPA observed one signal system button installed in one room and one signal system button being carried by a resident. The plan of correction for two citations were not completed by the due date. Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.the state’s words, verbatim · CDSS document, Aug 5, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Aug 6, 2025

...Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Based on LPA observation, hot water in the bathroom sink by room 8 measured at 126.5 degrees F which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Representative stated a third party will come and adjust water temperature for the facility. LPA to verify on a future visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(i) · Plan of correction due date: Aug 12, 2025

...All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall...Operate from each resident's living unit...Identify the specific resident living unit. This requirement is not met as evidenced by: Based on LPA observation, only one living unit had a signal system installed with poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Representative stated the signal system will be fully incorporated into each room by POC due date. LPA to verify on a future visit.

Type of visit: POC

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit for the purpose of conducting a Plan of Corrections Inspection for deficiencies issued on 05/21/2025 during the required annual inspection. LPA was greeted and granted entry by Director of Memory Care Amy Kaplli and discussed the purpose of the visit. LPA toured the facility to check the deficiencies have been corrected with staff. LPA verified smoke alarm was replaced in room 19 and fruit flies had been eradicated from the prep kitchen. The facility is still working on replacing some components in the fire systems and should be providing a service report to LPA by 06/04/2025 to correct the deficiency. Water temperature in the bathroom by room 8 measure 127 degrees F, higher than previous reading of 89.9 degrees F during the annual inspection. Facility has until 06/04/2025 to correct the deficiency. The emergency disaster drill is scheduled for 05/30/2025 at 2pm. Facility has until end of day 05/30/2025 to clear the deficiency. Based on LPA's observation on today's visit, LPA is unable to clear any deficiencies at this time. An exit interview was conducted and a copy of this report was provided to the facility representative.the state’s words, verbatim · CDSS document, May 30, 2025

Type of visit: Required - 1 Year

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 40 non-ambulatory residents of which 15 may be bedridden. Facility has an approved hospice waiver for 15 residents. Administrator (AD) Rose Nakadaira arrived shortly to facilitate visit. AD provided updated liability insurance that expires on 06/01/2025. LPA along with staff toured the facility at 9:30 AM. LPA toured the physical plant, checked food service, and facility documentation. The facility consists of 22 resident bedrooms, living areas, dining room/activities room, prep kitchen and full kitchen as well as 8 shared resident bathrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed there is no resident signal system in the resident bedrooms. At 10:30am, LPA observed missing smoke alarm in room 19. Resident bathrooms were checked. Toilets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 89.9 degrees F and 119.8 degrees F in all bathrooms checked. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. At 9:50 am, LPA observed fruit flies hovering in the prep kitchen next to the activities room. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPA toured the full kitchen. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough.Outside grounds were toured. Walkways around the facility were clear of hazards. There is shaded outdoor seating for residents. Exit gate is unlocked and operational. Continued on LIC809-C dated 05/21/2025 LPA observed the emergency food and water supply. LPA reviewed five resident files and five staff files. All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPA reviewed medication storage and administration. Medications are stored in a locked cart. Medications are being administered per physician order. Facility did not have fire system maintenance records dated within the last 12 months. Facility did not have records of emergency drills occurring within the last 3 months. Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.the state’s words, verbatim · CDSS document, May 21, 2025

The state marks this report as 8 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Office

On this day at 11am, a meeting was conducted by Assistant Program Administrator (APA) Stacy Barlow to verify Chapter 7 Bankruptcy Report filed by the Pacifica Senior Living as reported by the media. Present during the meeting are: Shelly Gracce - Assistant Branch Chief, CCLD Craig Lundgren - Legal Counsel, CCLD Carl Knepler - Chief Executive Officer, Marlene Nelson - Director, Quality Assurance and Risk Management APA Barlow verified with Knepler information received by CCL from the media as follows: $25M lawsuit against the community located in Bakersfield Phtography lawsuit against one of the properties lawsuit against a Killed Nursing Facility (SNF) in the Healdsburg location Knepler states that despite the lawsuits, there is no financial impact to any of the properties, residents or staff of the company. Knepler added there are no vendor issues as well. continuation on Lic 809C ***Original signature on file with the Pacifica Senior Living Union City facility.*** Knepler also states that management communicates with the staff and residents to make them aware of the changes. Signages have been changed. Knepler added that the bankruptcy did not affect any of the communities because Pacifica Senior Living Management was no longer the management company for any of the Pacifica Communities, that the communities had given notice to the department and residents back in October or November of last year of the changes in management companies. He said that the judgment in Bakersfield did not involve the operating entity, only the management company. He said there were no other suits pending against any of the Pacifica entities. APA requested the following documents be provided to CCL by today: Spread sheet of all facilities whose management company was/is Pacifica Senior Living Management Company management companies for each location letter provided to the residents notifying them of the changes At the conclusion of the meeting, APA emphasized to Knepler the importance of communicating with CCL any lawsuits that the company may have in the future. Knepler agreed with APA. A copy of this report was provided to Knepler. *** Original signature on file with the Pacifica Senior Living Union City facility.***the state’s words, verbatim · CDSS document, Apr 4, 2025

Allegation investigated: Facility did not ensure that modified diets prescribed by a resident's physician as a medical necessity was provided.

Licensing Program Analyst (LPA) Jenifer Tirre met with Executive Director Rose Nakadaira and Memory Care Director Amy Kaplli for the purpose of delivering findings for the above allegations. The complaint consisted of interviews, record review, and observations. On October 23, 2024 the department received allegations that facility did not ensure that modified diets prescribed by a resident’s physician as a medical necessity was provided. The investigation was completed by the Department and revealed the following: Based off interviews with staff, eight out of eight staff interviewed stated that they were all aware Resident 1 (R1) had a special pureed diet. Six of eight staff stated that they are notified of diet and or medication changes via a group chat that is sent out via text message to staff phones. Five of eight staff were aware that R1 had an incident where they were not given a pureed meal and aspirated on food. Three of eight staff members interviewed stated that R1 was fed meal by staff 1 (S1) where R1 aspirated and stated that S1 did not review group message that was sent out regarding R1’s puree diet. CONTINUED ON 9099C Substantiated Two of eight staff stated that S1 has a history of being out of compliance at work and not following directions. Interview with kitchen staff confirmed that facility has a binder for residents who have special diets that gets updated when changes are made. Based off records review, an incident report dated 10/11/2024 states that R1 was fed eggs by S1 and aspirated. Incident Report states that 911 was called and resident taken to hospital. Narrative Charting notes dated for 10/15/2024 stated that R1 was aspirating during dinner, 911 was called and paramedics arrived and suction R1. Record review of menu for October 11, 2024 for breakfast was Sausage Link, choice of cereal, pancakes and choice of juice. Menu did not match what witness reported R1 eating that day. Staff Schedule does confirm that S1 was working AM shift on October 11, 2024. Residents Physician’s Report dated 9/6/24, Preplacement Appraisal dated 9/9/24, and Needs & Service Plan dated 9/13/24 all state that R1 has a pureed diet with thickened liquids, water and Juice. Needs & Service plan states that “Residents goals for meals are to maintain adequate nutritional intake and allow enough time for resident to eat at a comfortable pace”. Preplacement Appraisal states under services needed, resident has special diet and observation of food intake. Collective Hospice Care Documents Revealed that R1 was admitted under Hospice Care on 10/16/2024. During initial visit on 10/30/2024, during facility tour LPA Tirre observed the following during visit: LPA reviewed Board in Kitchen with names of residents on special diets and observed that R1 was missing from board. LPA also attempted to view kitchen binder that has special diet orders for residents and was informed that a staff member borrowed binder and had not returned. LPA observed R1 to be sleeping in bedroom during visit and was unable to interview. Based on interviews, records reviewed and observations the preponderance of evidence has been met, deeming the allegations Facility did not ensure that modified diets prescribed by a resident’s physician as a medical necessity was provided is deemed SUBSTANTIATED. The following deficiencies are being cited per Title 22. A exit interview was conducted with Executive Director Rose Nakadaira. A copy of this report, confidential names list and appeals right was provided to facility.the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 22-AS-20241023094545

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(1)(8) · Plan of correction due date: Mar 13, 2025

87705 Care of person with Dementia(b) Licensees shall be responsible for the following: (1) ensuring staff receive the following training as part of the training requirements specified in Section 87208 Plan of Operation: (B) Recognizing symptoms that may create or aggravate behavioral expression, as defined in Section 87101, Definitions, including, but not limited to, dehydration, UTI's, and problems with swallowing.This requirement was not met as evidenced by R1 was fed solid food and aspirated when physician’s report, appraisal and needs & service plan stated R1 was on a special pureed diet. This poses an immediate health, safety and or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 12, 2025

Plan of correction: Licensee to provide updated policy on Special diets & Activities of Daily living for residents and provide in service training with signatures of staff. Licensee to provide plan of correction by due date 3/13/2025.

Allegation investigated: Medication was not administered to residents appropriately

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) Rose Nakadaira and explained the reason for today’s inspection. The investigation into the allegation that medication was not administered to residents appropriately revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, and the facility’s Medication Administration Records. CONTINUED Substantiated It was alleged that a resident was prescribed a medication to be taken every day for 21 days, but was only given the medication for three days. LPA inspected the facility, conducted health and safety checks on all residents present, and did not observe any health and safety issues. LPA interviewed AD who denied the allegation. LPA interviewed three staff and did not obtain information corroborating the allegation. LPA interviewed 10 residents and did not obtain information corroborating the allegation. LPA inspected the medications for these 10 residents and noted no medication errors. However, LPA reviewed the Medication Administration Records for these 10 residents and noted that all 10 residents have missed doses of medications in the last three months due to the medications not being in stock at the facility, including medications for blood pressure and heart conditions. Per AD, reasons for these medications not being in stock at the facility include residents’ families not bringing in the medications and doctors not timely providing refill prescriptions before the medications ran out. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. It was alleged that a resident sustained an injury at the facility, received stitches and needed their bandages changed daily, but the bandages were not changed for over three or four days. LPA inspected the facility, conducted health and safety checks on all residents present, and did not observe any health and safety issues. LPA interviewed AD who denied the allegation. LPA interviewed three staff and did not obtain information corroborating the allegation. LPA interviewed 10 residents and did not obtain information corroborating any unsafe conditions, lack of medical treatment, or issues regarding care and supervision. LPA reviewed recent wound care records which showed that the most recent wound at the facility was properly treated and had healed. Interviews with AD and staff revealed that the facility is properly identifying residents with wounds, ensuring they receive proper wound care, and ensuring wound care is properly documented. The information obtained did not corroborate the allegation. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Mar 10, 2025 · control 22-AS-20210617131615

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 11, 2025

87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure 10 out of 10 residents received assistance with medications when the facility ran out of supply, which poses an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Mar 10, 2025

Plan of correction: The licensee stated they will submit a plan to ensure residents medications are refilled timely to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA’s) Bernadette Allen made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Liam Larson who greeted LPA and assisted with the tour of the facility. At 10:00 AM the Administrator Rose Nakadaira arrived at the facility and she was informed of the purpose of the visit. Physical Plant: LPA observed there are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms: they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. The hot water temperature was tested throughout the facility which was within regulation 104-124 degrees F. The facility is equipped with operating smoke detectors, carbon monoxide alarms and fully charge fire extinguishers. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins,and other dangerous items were kept inaccessible to clients in care. There was a designated place for client/staff files . Overall, the facility appeared to be clean, in good repair, and operating in safe conditions. Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. LPA also observed emergency food supply and water. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed three (3) client files for admission agreements, updated physician reports, and Medication Administration Records (MAR’s) which appeared to be administered as prescribed by their physicians. LPA also reviewed Three (3) staff files for First Aid/CPR certification, annual training's, health screenings and the files reviewed were not complete/current. Based on LPA's observations a citation was issued for not having the staff files current. An exit interview was conducted, and this report was discussed and provided to Administrator Rose Nakadaira at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 22, 2024