Novellus Clairemont

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Type of visit: POC

Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to initiate a complaint and, in conjunction, conducted this case management visit for a plan of correction and to amend a report for complaint control # 08-AS-20260729102848. LPA Lopez identified herself and was granted entry by Amber Kauwoh, concierge. LPA Lopez stated the purpose of the visit and reviewed the basic elements of the visit with Executive Director Lane Hermosillo. On August 4, 2026, LPA Lopez delivered findings to complaint control #08-AS-20260729102848. LPA inadvertently omitted their signature in the signature box on page 1. During today’s visit, LPA signed the LIC9099 page in the signature box below and provided the facility with the amended report. On the same date, 08/04/2026, a case management visit was conducted, and the facility was provided two plans of correction (POC’s). The first POC was due on 08/05/2026, and LPA received the email on 08/05/2026. The second POC was due on 08/21/2026. LPA received an email on 08/25/2026 with the POC, the invoice receipts for the AC units and the fans for the facility. Although the POC was provided to LPA, the deadline lapsed by three days, and a civil penalty of $100 per day will be assessed to the facility for the time lapsed and may be found on the LIC421FC page attached to this report. An exit interview was conducted with Executive Director Lane Hermosillo, to whom a copy of this report, LIC421FC, and Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, Aug 31, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to obtain signatures on an amended report. During today’s visit, LPA was greeted by the Executive Director Lane Hermosillo, identified herself and met and discussed the purpose of the visit. During today’s visit, LPA obtained Executive Director Lane Hermosillo signature on an amended version of a report originally delivered on August 21, 2026. An exit interview was conducted with Executive Director Lane Hermosillo and a copy of this report and the Appeal Rights (LIC 9058 3/22) were provided.the state’s words, verbatim · CDSS document, Aug 27, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to initiate a complaint investigation and in conjunction conducted this case management visit. LPA Lopez identified herself and was granted entry by concierge Amber Kansenlate. LPA Lopez stated the purpose of the visit and reviewed the basic elements of the visit with Business Officer Vanessa Padilla. During the visit, LPA Lopez toured the second floor and was reviewing records in their Library around 9:45 am in the morning. While doing so, LPA observed that the temperatures in the room were exceedingly hot and observed that the temperatures were at 80ºF. Upon Executive Directors’ arrival, LPA inquired if they could turn on the air conditioner and they said that it was not operable in the common areas of the second floor. Later that day, LPA returned and the room was still warm, but the common areas were warmer in temperature while walking around. LPA inquired with a resident passing by about the temperatures and they nodded their head yes and said that it was very warm. Upon interview with a resident #1 (R1), LPA observed that they had dirty bedding which were soiled of a brownish substance. An exit interview was conducted and a plan of correction was jointly developed with Business Office Manager Vanessa Padilla, to whom a copy of this report, along with Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, Aug 4, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(C) · Plan of correction due date: Aug 5, 2026

87307 (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. This requirement was not met as evidence by: Based on LPAs observation the facility did not ensure R1s bedding was clean which posed a health and personal rights risk to person in care.the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: The facility agreed to purchase new bedding for R1 and will be sending LPA the receipts of the purchase, by POC due date 08/05/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303 · Plan of correction due date: Aug 21, 2026

Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors... This requirement was not met as evidence by: Based on LPAs observation, interview, and records reviewed the facility did not ensure their AC units were operable which posed a potential health, safety and personal rights risk to residents in care, staff and visitors.the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: Business Office Manager will obtain fans and AC units in the common areas and submit receipts to LPA by POC due date, 08/21/2026.

Allegation investigated: Staff did not answer call button in a timely manner. Staff did not ensure that resident's incontinence needs were met.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to commence and conclude a complaint investigation. LPA was greeted by Concierge Alex Garcia, identified herself, and met with Executive Director (ED) Lewis to discuss the purpose of the visit. The investigation included staff and resident interviews, along with a review of facility and resident records. On April 13, 2026, the Department received a complaint alleging the facility did not provide timely attention to a pendant call and that staff did not provide incontinent care to Resident 1 (R1). A review of R1’s resident record revealed R1 was admitted to the facility on August 31, 2025. Records showed that at the time of admission, R1 was independent with all activities of daily living (ADLs), able to self-administer medications, and required the use of a walking device or wheelchair. In addition, an interview with the ED confirmed that R1 drove their own vehicle and transported their mobility devices independently. Unsubstantiated Records also noted R1 was diagnosed with COPD, diabetes, Parkinson’s, GERD, arthritis, and HIV at the time of admission. R1’s records further disclosed that R1 did not require incontinence care, although they occasionally experienced urgency. A review of R1’s records and staff interviews showed no change of condition or decline in ADLs prior to R1’s voluntary relocation. At the time of the visit, it was confirmed that R1 had voluntarily relocated to another facility on March 31, 2026. The ED also disclosed that prior to relocating, R1 began displaying behavioral and mental health concerns, such as hitting themselves in the head, although no previous behavioral concerns were documented in R1’s facility records. Additional review of resident records confirmed R1 was assessed at a care level of “0,” requiring no care, consistent with their medical records maintained at the facility. Interviews with staff revealed they had no knowledge of R1 being incontinent, nor was incontinence care included in R1’s care plan. Interviews with other residents corroborated that they were unaware of R1 experiencing incontinence. LPA attempted to contact R1 multiple times but was unsuccessful. Additional staff interviews confirmed R1 was independent with all ADLs, including toileting. Regarding the allegation that staff did not respond in a timely manner to a pendant pull from R1, a review of the facility’s pendant call logs from March through April showed no pendant pulls initiated by R1. Interviews with residents (R2–R4) revealed no concerns with staff response time. One resident (R2), who lived directly next door to R1 and had regular communication with them, reported that R1 frequently expressed feelings that others were “out to get them” and tended to have “a chip on their shoulder.” Residents interviewed expressed satisfaction with staff and the services provided. R2 stated that “staff have been nothing but good to them.[See LIC 811 for confidential names list] Based on record review and interviews, the allegations that the facility did not provide timely attention to a pendant call and that staff failed to provide incontinence care to R1 were determined to be Unsubstantiated. An exit interview was conducted with ED Lewis who was notified a copy of the report will be provided at the conclusion of the visit. Signature below confirms receipt of the reports *LPA took a lunch break during the visit.the state’s words, verbatim · CDSS document, Apr 14, 2026 · control 08-AS-20260413114921

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to obtain signatures on an amended report. During today’s visit, LPA was greeted by the Business Office Manager (BOM) Padilla, identified herself and met and discussed the purpose of the visit. During today’s visit, LPA obtained BOM Padilla's signature on an amended version of a report originally delivered on December 8, 2025. An exit interview was conducted with BOM Padilla and a copy of this report and the Appeal Rights (LIC 9058 3/22) were provided.the state’s words, verbatim · CDSS document, Dec 10, 2025

Allegation investigated: Staff did not provide resident with a refund.

Licensing Program Analyst (LPA) Correia conducted an unannounced visit to commence and conclude a complaint investigation. LPA Correia was met by Concierge Angele Reyes, identified herself, and subsequently met with Business Office Coordinator (BOC) Vanessa Padilla to whom it was explained the purpose of the visit. The Department’s investigation consisted of a review of R1’s facility records and a review of outside source records, a tour of R1’s room, and outside source interviews. On November 21, 2025, the Department received a complaint that alleged the facility would not provide a refund for the number of pre-paid days after R1 had relocated. This is an amended version of the original complaint delivered on December 8, 2025. Unsubstantiated Outside Source (OS1) interview revealed R1 gave the Executive Director (ED) verbal notice they were going to vacate the facility on October 14, 2025. Although there was no documentation of written notice to vacate on October 14, 2025, records were secured dated October 16, 2025, that confirmed the ED had received R1’s notice. However, on October 18, 2025, a record review revealed R1 asked the ED to put a hold on their 30-day notice to vacate after encountering an issue with their new location, in which the ED agreed and on November 3, 2025, the ED sent out a notice to the corporate office that R1 would be resuming their place at the facility. Subsequently, on November 11, 2025, a record review revealed R1 notified the ED that they would not be returning to the facility, and on November 17, 2025, a moving company picked up R1’s belongings and removed them from the facility. Although there were 13 days of unused prepaid (November 18th through November 30th) days of rent, due to R1 recanting their notice to vacate on November 11, 2025, the facility held R1’s room with an expectation of their return and did not seek a new admit. During LPA Correia’s initial visit on December 1, 2025, she conducted an inspection of R1’s room at the facility. LPA observed the room to be vacant, and readily available to house a new resident. Based on the interviews and reviews of records the Department’s investigation determined the allegation to be Unsubstantiated. An unsubstantiated finding means there was not a preponderance of evidence to prove the violation occurred. An exit interview was conducted with ED Lewis. A copy of this report (LIC 9099), and the Licensee Rights (LIC 9058) was provided to ED Lewis. Signature below confirms receipt of the reports.the state’s words, verbatim · CDSS document, Dec 8, 2025 · control 08-AS-20251121091920

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) Ernest "EJ" Lewis and Maintenance Director Perry Garrett. The facility's license shows a maximum capacity of two-hundred-and-fourteen non-ambulatory residents, eight (8) of which may be bedridden. Bedridden residents may only reside in bedrooms 124-137. Additionally, the facility is approved for fifteen (15) hospice residents and does not accept Dementia residents. During today’s inspection there were eighty-nine (89) residents in care. Note, LPA did step out for lunch from 12-1pm. LPA and ED Lewis toured the interior and exterior of the facility and inspected a sample of occupied and unoccupied resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: bathroom sink in an unoccupied unit was 105.6F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were inaccessible to residents in care. [Continued on LIC 809-C] [Continued from LIC 809] No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per ED Lewis, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months, dated for service in September 2025. Last emergency drill conducted was on 10/3/25 for the topic of fire. The facility maintained excellent record keeping for maintenance and fire safety items. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed one (1) staff and one (1) client, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents, however LPA noted that staff training in the sampled records did not cover all required topics and a Type B citation was issued. Confidential records were stored in locked areas. During file review, LPA did also note that a bedridden resident (R1) was residing in a non-bedridden approved unit and had a Dementia diagnosis, which the facility's license does not approve. Two (2) additional type B citations were issued for the fire clearance violation and for operating beyond the conditions of their license. Three (3) deficiencies total were cited during the inspection. An exit interview was conducted with ED Lewis to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Oct 22, 2025

Allegation investigated: Staff are mismanaging resident's medication.

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced visit to deliver findings regarding the above-mentioned allegation. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit with Executive Director Ernest Lewis. On 2/28/25, it was alleged that the facility is mismanaging a resident’s (identified as R1) medication. The Department’s investigation consisted of unannounced facility visits, records review, and interviews with staff, residents, and outside sources. [Continued on LIC 9099C] Unsubstantiated [Continued from LIC 9099] While some staff interviews revealed that the facility has previously had some issues with medication management, no staff members interviewed indicated that R1’s medications were mismanaged. Review of facility records for R1 revealed a documented history of medication refusals, and all staff interviewed corroborated that R1 often did so. Staff interviews and facility records also corroborated that R1 regularly consumed alcohol, despite meetings facilitated by the facility on the risks of R1 mixing alcohol with their specific medications. Resident interviews did not reveal any concerns about medication management or their care. One resident interviewed recalled R1 and revealed that staff would bring medications for R1 routinely. Outside source interviews revealed no concerns about medication management. Based on interviews and records review, while the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred – therefore the allegations have been determined to be UNSUBSTANTIATED. An exit interview was conducted with Executive Director Lewis to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 7, 2025 · control 08-AS-20250228100611

Allegation investigated: Staff did not administer medication as ordered Not enough staff to meet residents needs

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. Upon arrival, LPA was greeted by Executive Director (ED) EJ Lewis, identified herself, and explained the purpose of the visit. Investigation Overview Community Care Licensing (CCL) initiated an investigation in response to a complaint received on May 29, 2024. The complaint alleged that staff failed to administer medication as ordered and that there was an insufficient number of staff to meet the needs of residents. To evaluate these allegations, the CCL conducted an onsite inspection of the facility, reviewed facility records, and conducted multiple interviews with staff, residents, and external sources. These investigative methods were used to assess the facility’s compliance with applicable laws and regulations during the relevant time period. (continue at LIC9099C) Substantiated (Continue from LIC9099) According to the complaint, residents were receiving their medications late due to a shortage of staff available to administer them. It was reported that between February and May 2024, the facility experienced a shortage of medication technicians and direct care staff. However, no specific details were provided regarding which residents were affected or the specific dates and times when medication was administered late. Findings CCL conducted interviews with staff, residents, responsible parties, and external sources, all of which consistently corroborated both allegations. Staff interviews revealed ongoing concerns regarding inadequate direct care staffing during the period in question. Management acknowledged the use of external staffing agencies to fill gaps and compensate for staffing shortages. During visits conducted on June 3, 2024, and April 10, 2025, LPA observed the Executive Director acting as a medication technician due to staff shortages. Interviews with staff and residents confirmed that the Executive Director and other non-direct care staff were frequently reassigned to cover care shifts. As a result, medication administration was often delayed. While no adverse health outcomes were reported due to delayed medication, residents’ other care needs were not consistently met. Interviewees stated that services such as incontinence care, showering, grooming, laundry, and housekeeping were often delayed or incomplete. For example, maintenance staff were observed doing laundry, and housekeeping staff were assisting with food service duties. Management and staff indicated they were making efforts to meet residents’ needs but acknowledged that there were not enough staff available to maintain adequate care. It was further explained that the facility was experiencing challenges in remaining competitive within the industry and had to rely heavily on outside staffing agencies. As of May 2025, the facility is under new management. The current administration has prioritized increasing staffing levels to ensure resident care needs are met. Follow-up interviews with staff, residents, and external sources confirmed that current staffing is adequate. (continue at LIC9099C) (Continue from LIC9099C) Conclusion Based on the evidence obtained through observations and interviews, CCL substantiates both allegations using the preponderance of evidence standard. Deficiencies were cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations and are detailed on the LIC 9099-D form. A Plan of Correction (POC) was developed in coordination with ED EJ Lewis. An exit interview was conducted with ED Lewis, who was provided with copies of this report, the LIC 9099-D Deficiency Report, and the LIC 9058 (03/22) Licensee Appeal Rights.the state’s words, verbatim · CDSS document, Jul 30, 2025 · control 08-AS-20240529111937

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Sep 1, 2025

87465(c)(2) Incidental Medical and Dental Care Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on observations and interviews with staff and external sources, the licensee failed to ensure medications were administered as ordered. This posed a potential health risk to 69 residents in care.the state’s words, verbatim · CDSS document, Jul 30, 2025

Plan of correction: The licensee agreed to conduct in-service training for staff on proper medication administration. Documentation of this training will be submitted to CCL by the POC due date 9/1/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Sep 1, 2025

87411(a) Personnel Requirements - General 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 observations, the licensee failed to maintain a sufficient number of staff to meet residents’ needs. This posed a potential personal rights risk to 69 residents in care.the state’s words, verbatim · CDSS document, Jul 30, 2025

Plan of correction: The licensee agreed to maintain staffing levels sufficient to meet resident needs and to provide in-service training on resident service care plan requirements. The facility will submit a staffing plan and documentation of the training completed by the POC due date 9/1/2025.

Allegation investigated: Staff neglect resulted in resident's hospitalization Staff did not seek medical attention to meet resident's needs Staff did not meet resident's incontinence needs

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. Upon arrival, LPA was greeted by Executive Director EJ Lewis. LPA identified herself and explained the purpose of the visit. Investigation Overview Community Care Licensing (CCL) initiated an investigation in response to a complaint received on April 4, 2025, alleging that staff neglect resulted in the hospitalization of Resident 1 (R1), that staff did not seek medical attention to meet R1’s needs, and that incontinence care was not provided. A Confidential Names List (LIC 811) was provided to staff to identify R1. To investigate these allegations, the Department conducted an onsite facility inspection, reviewed facility records and medical documentation, and conducted multiple interviews with facility staff, residents, and external sources. (continue at LIC9099C) Substantiated (Continue from LIC9099) Through these investigative methods, the Department assessed the facility’s compliance with applicable laws and regulations, as well as the quality of care provided to R1 during the period in question. According to the complaint, on April 3, 2025, at approximately 7:30 a.m., during the administration of morning medications, staff observed a change in R1’s condition and initiated a 911 call. R1 was subsequently transported to the hospital by emergency personnel. The incident report submitted to CCL indicated that R1 exhibited signs consistent with a stroke, including facial drooping on the right side, confusion, and general weakness. Resident Background A review of R1’s medical records showed that upon admission to the facility in March 2024, R1 required maximum assistance with all activities of daily living. R1 had multiple chronic medical conditions, including malignant neoplasm of the prostate and bone, a history of urinary tract infections (UTIs), repeated falls, malnutrition, and anemia. The functional needs service plan dated April 5, 2024, stated that R1 was at heightened risk for sudden changes in condition and required close observation and monitoring. The service care plan for R1 also required full assistance with incontinence care, grooming, bathing, dressing, ambulation, transfers, and escorting. Additionally, R1’s Foley catheter was to be managed by an outside home health agency. Findings The Department reviewed hospital records and conducted multiple interviews with external sources, which confirmed that R1’s change in condition on April 3, 2025, was due to a severe bacterial infection (sepsis) originating from a UTI. External sources reported that R1 was admitted in a severely deteriorated state and required care in the intensive care unit (ICU) for four days, followed by an additional ten days of hospitalization. R1 also tested positive for COVID-19, was dehydrated, and had multiple pressure ulcers. Interviewees reported that R1 arrived at the hospital saturated in urine from the shoulders down. Additionally, R1 experienced a significant and undocumented weight loss—from 64 kg on March 5, 2025, to 51.7 kg on April 3, 2025. Staff confirmed that this weight loss and overall change in condition were neither observed nor reported to R1’s medical team, as required and missed an opportunity for timely medical intervention. (Continue at LIC9099C) (Continue from LIC9099C) Further, the investigation found that there were no records of home health agency visits after March 13, 2025. Staff stated they were unaware of why the visits had ceased, and the investigation could not determine whether the agency formally discontinued services. Staff interviews consistently revealed concerns about insufficient direct care staffing. Staff interviews consistently indicated that staffing shortages were an ongoing issue during the time of the incident. Management acknowledged the use of an external staffing agency to fill gaps and to compensate for direct care staff shortages. During a visit on April 10, 2025, it was observed that the Executive Director was acting as a medication technician due to staff callouts. Interviews with staff and residents further confirmed that non-direct care staff were frequently pulled to cover care shifts, and medication administration was often delayed due to staffing shortages. While no adverse outcomes from late medication administration were reported, it was confirmed that incontinence care was not provided to R1 before the arrival of emergency personnel on April 3, 2025, due to a short-staffed night shift. A review of the facility’s staffing schedules for the relevant period could not verify whether all scheduled shifts were adequately staffed, as coverage for unscheduled absences was not consistently documented, and not all the staff involved were available to comment. As of May 2025, the facility is under new management. The current administration has prioritized increasing staffing levels to ensure sufficient care. Follow-up interviews with staff, residents, and external sources confirmed that current staffing is adequate to meet residents’ needs. Conclusion Based on the evidence obtained through interviews, observations, and a review of records, the Department determined that there is sufficient evidence to substantiate the allegations. Staff neglect resulted in R1’s hospitalization, medical attention to meet R1 needs was not appropriately addressed, and incontinence care was not adequately provided to meet R1’s needs. (Continue on LIC9099C) (Continue from LIC9099C) The Department finds the allegations to be substantiated, meeting the preponderance of evidence standard. Deficiencies were cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations, and are detailed on LIC 9099-D. A Plan of Correction (POC) was developed with Executive Director EJ Lewis. In accordance with Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted with Executive Director Lewis, who was provided with a copy of this report, the LIC 9099-D Deficiency Report, the LIC 811 Confidential Names List, and the LIC 9058 (03/22) Licensee Appeal Rights.the state’s words, verbatim · CDSS document, Jul 30, 2025 · control 08-AS-20250404143359

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(e) · Plan of correction due date: Sep 1, 2025

Section 87463 (e) – Reappraisals The licensee shall immediately, or as soon as reasonably possible, bring any significant change in condition to the attention of the appropriate licensed medical professional. This requirement was not met as evidenced by: Based on observations, records review, and interviews with staff and outside sources, staff neglect resulted in the resident's (R1) hospitalization. This posed an immediate health, safety, and personal rights risk to one 1 of 84 residents in care.the state’s words, verbatim · CDSS document, Jul 30, 2025

Plan of correction: The licensee agreed to conduct staff training on regulations regarding timely evaluations and reappraisals. Documentation of the training will be submitted to CCL by the POC due date 9/1/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Sep 1, 2025

Section 87466 – Observation of the Resident. The licensee shall ensure residents are regularly observed…when changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician. This requirement was not met as evidenced by: Based on observations, records review, and interviews with staff and outside sources, the licensee did not seek medical attention to meet the resident's needs (R1). This posed a potential health, safety, and personal risk to one 1 of 84 residents in care.the state’s words, verbatim · CDSS document, Jul 30, 2025

Plan of correction: The licensee agreed to ensure adequate staffing levels and provide staff training on monitoring and documenting changes in residents’ conditions. The facility will submit staffing plans and documentation of completed training by the POC due date 9/1/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2) · Plan of correction due date: Sep 1, 2025

Section 87625(b)(2) – Managed Incontinence. In addition to Section 87611, …the licensee shall be responsible for the following: Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This requirement was not met as evidenced by: Based on records review, interviews with staff, and outside sources, the licensee did not provide incontinent care to meet R1’s needs. This posed a potential health, safety and personal 4risk to one 1 of 84 residents in care.the state’s words, verbatim · CDSS document, Jul 30, 2025

Plan of correction: The licensee will provide in-service training on proper incontinence care protocols and submit documentation of staff training by the POC due date 9/1/2025..

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director Ernest "EJ" Lewis. Community Care Licensing received an Incident Report on 5/22/25 in which it was reported that Resident #1 (R1) was found unresponsive by care staff during morning rounds. Emergency services were called and R1 was pronounced deceased. Due to unknown cause of death, LPA conducted follow-up. During today's visit, LPA conducted file review and provided consultation with Executive Director Lewis. No Deficiencies were cited during the visit. An exit interview was conducted with Executive Director Lewis to whom a copy of this report was provided. Their signature below confirms receipt of this document.the state’s words, verbatim · CDSS document, May 30, 2025

Allegation investigated: Staff did not maintain dining room at a comfortable temperature

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced complaint investigation visit to conduct additional interviews and deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director (ED) Emily DeLaBarre. Throughout the investigation, the Department secured records and attempted interviews with external and internal sources, including staff and residents. It was alleged staff did not maintain the dining room at a comfortable temperature. On 12/26/2024, it was reported to the Department the dining room was often at a colder temperature, staff were made aware, but it was not addressed. Interviews with staff and residents confirmed the dining room was often colder in the mornings, that this was reported to the maintenance staff, but it was not addressed. (See LIC 9099C for continuation of report.) Substantiated The maintenance staff were the only staff who had access to the locked thermostat in the dining room. There were times when the maintenance staff did not respond to the requests to adjust the thermostat, until several hours had elapsed. There was occasions where the air conditioning setting was turned off, but the heater was not turned on. This led to some residents leaving the dining room, eating their breakfast elsewhere, or retrieving jackets and returning to the dining room. Although interviews with the ED and Maintenance Director revealed they were recently made aware of the dining room being too cold, and observations by the LPA noted the thermostat at sixty-eight degrees (68 degrees F) and seventy-three degrees(73 degrees F), there was enough evidence to determine staff, including the ED and Maintenance Director, had knowledge of this concern for several months and did not address it. Based on evidence obtained, the allegation was substantiated and cited in an LIC 9099D page. A plan of correction was jointly formulated with ED DeLabarre. An exit interview was conducted with ED DeLaBarre, to whom a copy of this report, LIC 9099D, and Licensee/Appeals Rights (LIC 9058), were provided via email. An email read receipt confirms the documents were received by the ED.the state’s words, verbatim · CDSS document, Jan 24, 2025 · control 08-AS-20241226101847

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b) · Plan of correction due date: Jan 24, 2025

87303 Maintenance and Operation (b)A comfortable temperature for residents shall be maintained at all times. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure the dining room was maintaned at a comfortable temperature, which posed a potential health, safety, and personal rights risk to all residents in care.the state’s words, verbatim · CDSS document, Jan 24, 2025

Plan of correction: ED removed the lock on the thermostat to allow multiple staff access. ED also agreed to provide in service training to all staff regarding facility temperatures, and submit proof of training the LPA by 2/7/25.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management visit. The LPA identified himself and disclosed the purpose of the visit to Executive Director Emily DeLaBarre. On 12/09/2024, the Department received an incident report indicating Resident # 1 (R1) had sustained a fall that was not witnessed, on 12/05/2024. R1 initially declined having pain, but later reported pain and was transported to the hospital. R1 was discharged with not fractures. On 12/12/2024, R1 reported excruciating pain and was transported to the hospital and diagnosed with a pelvic fracture. Review of records revealed R1 had a CT scan and several X-ray exams preformed during R1's hospital visit on 12/05/2024. These exams did not reveal any fractures and R1 was discharged back to the facility. Per interview with Executive Director DeLaBarre, R1 did not sustain any additional falls between 12/05/2024 and 12/12/2024. At this time,R1 is still at the hospital receiving treatment. Additional visits and review of additional pending records is necessary. An exit interview was conducted with Executive Director DeLaBarre, to whom a copy of this report, and Licensee/Appeal Rights (LIC 9058), were provided via email. An email read receipt confirms the documents were received.the state’s words, verbatim · CDSS document, Jan 2, 2025

Allegation investigated: Staff did not provide resident medication as prescribed.

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced follow up complaint investigation visit, and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Emily De La Barre. It was alleged staff did not provide resident medication as prescribed. On 10/07/2024, it was reported to the Department staff did not provide Resident # 1 (R1) prescribed medication. Although R1’s Physician’s Report noted that R1 did, and also noted R1 did not require assistance with medication management, review of R1’s care plan revealed R1’s did not require medication management, nor a service for medication assistance. Interviews with R1 and the facility administrator corroborated R1 managed R1’s medication and did not require assistance with medication management. Based on the evidence obtained, the allegation was Unsubstantiated. (See LIC 9099C for continuation of report.) Unsubstantiated An exit interview was conducted with De La Barre, to whom a copy of this report, LIC 811 Confidential names list, and Licensee/Appeals Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Nov 19, 2024 · control 08-AS-20241007090449

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Continuation Annual Inspection. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Emily De La Barre. The facility was licensed for a capacity of two hundred fourteen (214) non- ambulatory residents. Eight of these residents could be bedridden in bedrooms #124-137. The facility was also approved for a hospice waiver for fifteen (15) residents. The LPA randomly selected resident bedrooms and bathrooms, tested the water temperature, tested the facility signal system, and confirmed they were within the range required and operational. Bedrooms had the required furnishing, including dressers, bedding and lamps. One carbon monoxide detector was observed and tested during the tour. Licensing postings were visible in different areas of the facility. Staff and resident records were reviewed during the visit and interview conducted. The LPA provided technical advise and no deficiencies were cited on today's date. An exit interview was conducted with Executive Director De La Barre, to whom a copy of this report, and Licensee rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Nov 19, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management Visit. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Emily De La Barre. Today's visit was in response to an Unusual Incident Report (LIC 624) submitted to the Department on 10/24/24. It was reported Resident # 1 (R1) had eloped from the facility, police found R1, and escorted R1 back to the facility. During the visit, the LPA reviewed records and conducted interviews. Interviews and a review of R1's Physician Report (LIC 602) revealed R1 was no able to leave the facility unassisted. The LIC 602 also revealed R1 could be confused and was diagnosed with Mild Cognitive Impairment. Interviews with staff revealed R1 had previously attempted to leave the facility by walking out the front door, and without signing out, as indicated in facility's policy. Staff had redirected R1 and advised R1 of the facility's sign out process and to have staff accompany R1. Interviews with staff and an external source confirmed this was the first time R1 had left the facility unassisted. Although R1 had attempted to walk out of the facility previously, there was no clear indication that lack of supervision contributed to R1 leaving the facility. Additionally, interviews confirmed the facility notified R1's family and R1 was transported to the hospital for further assessment. No deficiencies were cited on today's date. An exit interview was conducted with Executive Director De La Barre, to whom a copy of this report, and Licensee/Appeal Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Oct 25, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. . The LPA introduced himself and disclosed the purpose of the visit to Staff Mercedes Heredia. Executive Director Emily De La Barre arrived during the visit and assisted the LPA. The facility was licensed for a capacity of two hundred fourteen (214) non- ambulatory residents. Eight of these residents could be bedridden in bedrooms #124-137. The facility was also approved for a hospice waiver for fifteen (15) residents. Accompanied by staff, the LPA toured the interior and exterior of the facility, and inspected bedrooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstructions and slip hazards Bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was two days of perishable food and seven days of non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled and stored in a locked area. Due to time constraints, a continuation visit on a subsequent day is necessary to complete the annual inspection. No deficiencies were observed, nor cited on today's date. An exit interview was conducted with Executive Director De La Barre, to whom a copy of this report, and Licensee Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Oct 23, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management visit. The LPA identified himself and disclosed the purpose of the visit to Business Office Manager Mercedes Heredia. Executive Director Emily De La Barre arrived during the visit and assisted the LPA. Today's visit was in response to an Unusual Incident Report (LIC 624) submitted to the Department on August 28th, 2024. The LIC 624 reported Resident # 1 (R1) had left the and was considered AWOL. During the visit, the LPA requested pertinent records and conducted interviews. Review of records, along with the interviews of staff and R1, confirmed the facility followed the facility's elopement procedures. There were no deficiencies cited on today's date. An exit interview was conducted with Executive Director De La Barre, to whom a copy of this report, LIC 811, and Licensee/Appeal Rights (LIC 9058), were provide.the state’s words, verbatim · CDSS document, Sep 24, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management visit. The LPA identified himself and disclosed the purpose of the visit to Executive Director Emily De La Barre. Today’s visit was in response to an Unusual Incident Report (LIC 624) received by the Department on 08/09/2024. The LIC 624 noted Resident # 1 (R1) had a fall and sustained a fracture. During the visit, the LPA secured pertinent records and conducted a tour of the facility. There was no immediate health, nor safety concerns observed. At this time, additional visits and follow up telephone calls may be necessary. An exit interview was conducted with Executive Director De La Barre. A copy of this report, LIC 811, and Licensee/Appeal Rights (LIC 9058) were provided to De La Barre via email. An email read receipt confirms the documents were received by De La Barre.the state’s words, verbatim · CDSS document, Aug 9, 2024

Allegation investigated: Licensee did not provide a refund

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Emily De La barre. Throughout the investigation, the Department secured pertinent records and conducted interviews with internal and external sources. It was alleged the Licensee did not provide a refund. It was reported to the Department the facility did not refund fees paid within the required timeframe, after a resident’s belongings were removed from the facility. An interview with the facility’s Executive Director confirmed Resident # 1 (R1s) belongings were removed from the facility on 01/06/24, and a refund check was not available until 02/02/24. The facility did not provide a refund within a fifteen (15) day period as indicated in the California Code of Regulations, Title 22. (See LIC 812 for continuation of report.) Substantiated The deficiency was cited in an LIC 9099D, and documentation was obtained by the LPA confirming R1’s responsible party received a refund. The Plan of Correction was cleared on today’s visit. An exit interview was conducted with De La Barre, to whom a copy of this report, LIC 9099D, and Licensee/Appeals Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Mar 6, 2024 · control 08-AS-20240129112107

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: Mar 6, 2024

1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds. (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. This requirement was not met as evidenced by: Based on interviews and review of records, the Licensee did not ensure fees were refunded within 15 days after R1's personal property was removed, which posed a potentilal health, safety, and personal rights risk to 1 of 74 residents.the state’s words, verbatim · CDSS document, Mar 6, 2024

Plan of correction: Interviews revealed a refund check was provided and received by R1's resposible party. POC is cleared on today's date.

Allegation investigated: Facility not providing an adequate amount of food to resident in care Facility overcharging resident in care

On 01/31/2024, at about 1:20 PM, Licensing Program Analyst (LPA), Daniel Pena conducted an unannounced visit to initiate a complaint investigation. LPA introduced and identified himself, and explained the nature of the visit to the receptionist. Executive Director, Emily DeLaBarre met LPA at the lobby. LPA discussed the elements of the complaint with Ms. DeLaBarre and delivered investigative findings at the conclusion of the visit. On 1/23/2024, Community Care Licensing Division (CCLD) received a complaint alleging the facility did not provide adequate food and overcharged a resident. No further details were communicated to CCLD. The Department’s investigation consisted of a facility visit, facility and resident record review and interviews with facility staff and outside sources. Records and interviews revealed that Resident 1 (R1) resided at an RCFE which closed on September 26, 2023. Licensing records show that after the former facility closed, the new owner, Novellus Clairemont, LLC assumed a new licensure. The newly licensed facility was opened at the same physical location but under new licensure. Unfounded Licensing records show the date Novellus Clairemont, LLC became active was October 1, 2023. Facility and outside agency records showed that on September 20, 2023, R1 was served with a legal eviction from the former licensed facility. Outside agency records obtained show that on 9/20/23, San Diego County law enforcement officers removed R1 from the property as part of an Eviction Restoration Notice (Court Case No. 37-2023-00027224). The order was directed in the San Diego County Superior Court. Licensing records and interviews confirm R1 was not a resident at Novellus Clairemont, LLC when the alleged violations and eviction occurred. Record reviews confirm there is no evidence R1 resided at Novellus Clairemont, LLC. The Department has investigated the allegation that the facility did not provide adequate food and overcharged a resident. Based on the results of the investigation, there was no evidence found to support the allegations listed in this report. The Department has found that the complaint allegations were Unfounded, meaning that the allegations were false, could not have happened, and/or are without a reasonable basis. An exit interview was conducted with Director, DeLaBarre, to whom a copy of this report, and Licensee Appeal Rights (9058 01/16) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 31, 2024 · control 08-AS-20240123132703

Allegation investigated: -Facility staff threatened resident -Resident was locked out of facility

Licensing Program Analyst (LPA), Natasha Persaud conducted a complaint investigation visit. LPA met with Executive Director, Emily DeLaBarre. During today’s visit, LPA briefly toured the facility, reviewed records, and interviewed resident and staff. It was alleged that staff threatened and locked Resident #1 (R1) out of the facility. It was reported R1 was locked out of the facility and was banging on the door for entry after hours. It was also reported Staff #1 (S1) threatened R1 by telling R1 to stop banging on the front door otherwise R1 will be written up. The facility has new ownership and once the new company took over, they made some policy changes. The old management company allowed residents and staff to have a master key to the front door. The new management company has changed the locks and new keys were not issued to the residents. The facility has a doorbell for afterhours access. Once activated, the doorbell rings to staff’s pager notifying them someone is at the front door. R1’s interview revealed they were not provided notice of the change in policy regarding the new locks. However, R1 observed the locks being changed by a professional company and upon their return hours later, they discovered the front door was locked. Continued on an LIC 9099C. Unsubstantiated The Executive Director’s interview confirmed an email was sent out to all residents and a copy was posted at the front desk for notification. The facility usually locks the door in the evenings around 5:30pm. The facility now has regular concierge services. Therefore, the door remains unlocked until approximately 8pm. The doorbell is accessible for after- hours access. The facility did not issue the new front door key to any residents for safety reasons. The facility did not lock R1 out of the facility. R1’s interview revealed conflicting statements that they were knocking on the door, then stated they were not knocking on the door for entry. R1’s interview also revealed S1 approached the front door to open it for R1 and told R1 to ring the doorbell and stop banging on the door. According to R1, they were going to be written up by S1 for banging on the door. No write ups were issued. S1’s interview confirmed they did not threaten R1. S1 revealed R1 was the individual that stated they were going to write S1 up, not the other way around. R1 wanted to use S1’s personal cell and S1 declined. R1 then asked to use a phone restricted to residents. When S1 denied access to the restricted phone, R1 made the comment about a write up. Further staff interviews confirmed staff are not threatening any residents and R1 usually threatens staff. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Emily DeLaBarre whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jan 3, 2024 · control 08-AS-20231227160957

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management visit. The LPA introduced himself and discussed the purpose of the visit with Business Office Manager Sam Elizondo. Resident Care Director Elaine Nunes assisted the LPA, and Executive Director Emily Delbarre joined via telephone. During the visit, the LPA discussed eviction procedures and collected pertinent records. An exit interview was conducted with Elizondo, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided via email. An email mail receipt confirmed the documents were received by Elizondo.the state’s words, verbatim · CDSS document, Dec 29, 2023