Novellus Stockton

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Kulich and LPA Albert Johnson conducted an unannounced complaint investigation that led to a Case Management (CM) on 09/14/2026. During the visit, LPA Kulich and LPA Johnson observed and photographed three (3) fire extinguishers, one (1) "K" system, and the ansul system were all out of compliance regarding their service dates by Jorgensen. The last recorded service date was 09/08/2025. Deficiencies cited on the attached 809D page. Exit interview conducted and appeal rights given.the state’s words, verbatim · CDSS document, Sep 14, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Sep 15, 2026

87203-All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Observation, records review three (3) fire extinguishers, one (1) "K" system, and the ansul system were all out of compliance regarding their service dates by Jorgensen. The last recorded service date was 09/08/2025. This is an immediate health and safety risk for all residents in care.the state’s words, verbatim · CDSS document, Sep 14, 2026

Plan of correction: The facility will repair or replace fire extinguishers and the fixed system to be in compliance within the state fire Marshall requirements by POC date. Facility will provide LPA with photo evidence of the services completed to bring fire safety equipment into compliance.

Type of visit: POC

LPA Johnson arrived to the facility unannounced to conduct a plan of correction visit. LPA met with the Administrator who assisted with the POC visit. The following deficiencies, initially cited during a visit on 12/05/2025, have been cleared: Section Cited: 87465(a)(4) Date Due: 12/08/2025 Plan of Correction: Facility staff agrees to conduct a medication audit from an outside agency by POC date 12/08/2025. Facility staff agrees to email LPA an audit plan by 12/08/25 Corrections: Cleared By Visit Clearance Date: 03/19/2026 Section Cited: 87207 Date Due: 12/08/2025 Plan of Correction: Facility staff agrees to conduct a medication in-service by POC date 12/08/2025. Facility staff agrees to email LPA a medication in-service plan by 12/08/2025. Corrections: Cleared By Visit Clearance Date: 03/19/2026 Section Cited: 1569.695(c) Date Due: 12/06/2025 Plan of Correction: Licensee will submit a proof of a completed fire /disaster drill to LPA by POC due date Corrections: Cleared By Visit Clearance Date: 03/19/2026Exit interview conducted.the state’s words, verbatim · CDSS document, Mar 19, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Staff and explained the purpose of the visit. LPA inspected the physical plant with including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 117 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. During the tour of the kitchen LPA observed sink with cracks in the seams, water pooling on the floor by the sink, expired food and holes in the floor tiles by the ovens. Fire extinguishers and smoke detectors/carbon monoxide detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. During the medication review LPA observed medications counts off for two controlled medications for R1. The medication is not listed on the centrally stored log and the other medication is listed on the log but there are two different quantities for these medication, which throws the controlled medication count off (There are approximately 10 pills missing from R1 medication ) LPA reviewed 10 resident and 5 staff files, including criminal record clearances. All staff are fingerprinted and cleared. First aid kit was checked and is complete. Deficiencies were cited pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conductedthe state’s words, verbatim · CDSS document, Dec 5, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 8, 2025

A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interviews, file review, and medication audit, the licensee did not comply with the section cited above. facility staff did not follow R1's oxycodone order and was not administered medication as noted on the controlled drug record and MAR. This posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 5, 2025

Plan of correction: Facility staff agrees to conduct a medication audit from an outside agency by POC date 12/08/2025. Facility staff agrees to email LPA an audit plan by 12/08/25

From the deficiency page — Deficiency type: Type A · Section cited: CCR87207 · Plan of correction due date: Dec 8, 2025

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: Based on file reviews, interviews, and medication audit, the licensee did not comply with the section cited above. A med-tech signed off on R1's controlled drug record that medication was administered when it was not administered. The medication (10+ pills are unaccounted for). This action also resulted in controlled medication count being off. This posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 5, 2025

Plan of correction: Facility staff agrees to conduct a medication in-service by POC date 12/08/2025. Facility staff agrees to email LPA an medication in-service plan by 12/08/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(17,28,29) · Plan of correction due date: Dec 12, 2025

The following food service requirements shall apply:(17) In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service. If this person is not a nutritionist, a dietitian, or a home economist, provision shall be made for regular consultation from a person so qualified. The consultation services shall be provided at appropriate times, during at least one meal. A written record of the frequency, nature and duration of the consultant's visits shall be secured from the consultant and kept on file in the facility. (28)All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. (29)All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by observation kitchen sink with cracks in the seams, water pooling on the floor by the sink, expired food in the walk-in refigerator and holes in the floor tiles by the ovens. This is a potential health and safety risk.the state’s words, verbatim · CDSS document, Dec 5, 2025

Plan of correction: The facility will repair or replace items listed and provide the departemnt with photo evidence of the corrections. The facility will also hire a required nutritionist, a dietitian, or a home economist to complete the required evaluation of kitchen services by the POC date 12/12/2025.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.695(c) · Plan of correction due date: Dec 6, 2025

§1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is notrequired during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by last recorded drill was 4/24/25the state’s words, verbatim · CDSS document, Dec 5, 2025

Plan of correction: Licensee will submit a proof of a completed fire /disaster drill to LPA by POC due date

Type of visit: POC

LPA Johnson arrived to the facility unannounced to conduct a plan of correction visit. LPA met with the Administrator who assisted with the POC visit. The following deficiencies, initially cited during a visit on 10/10/2025, have been cleared: Section Cited: 87555(b)(29) Date Due: 10/24/2025 Plan of Correction: The facility will repair or replace the items listed by the POC date of 10/24/2025. The facility will provide the department with documentation of the fixed items or receipts for the replaced items via email or fax. Corrections: Cleared By Visit Clearance Date: 10/27/2025. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 27, 2025

Type of visit: Case Management - Incident

LPA Johnson arrived to the facility unannounced to conduct a case management visit based on an incident reports submitted to the department on 10/5/2025. It was reported to the department that at approximately 3:30pm on 10/3/2025, R1 reported pain on the left side. R1 had an unwitnessed fall on 9/30/2025 and refused treatment by the emergency medical service on that day. R1 continued to be uncomfortable for three days until he requested to go to the ER to be evaluated on the afternoon of 10/3/2025. R1 was sent out and diagnosed with an UTI and multiple fractures of the ribs on the left side. Medications were ordered and follow-up with primary care physician (PCP) ordered by 10/6/2025 which is 3 days after the incidents or ER discharge. During the inspection LPA toured the facility and discovered multiple issues in the kitchen including, broken thermostat, equipment not operational, drainage issues resulting in puddling on the floor in front of the main oven, mirror not secured on the fireplace mantel and black smoke stains on the walls in the dining area. Deficiencies cited on the attached 809D page. Exit interview conducted and appeal rights given.the state’s words, verbatim · CDSS document, Oct 10, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(29) · Plan of correction due date: Oct 24, 2025

87555 General Food Service Requirements (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by observation multiple issues in the kitchen including, open seams in the sink, broken thermostat, equipment not operational, drainage issues resulting in puddling on the floor in front of the main oven, mirror not secured on the fireplace mantel and black smoke stains on the walls in the dining area.the state’s words, verbatim · CDSS document, Oct 10, 2025

Plan of correction: The facility will repair or replace the items listed by the POC date of 10/24/2025. The facility will provide the department with documentation of the fixed items or reciepts for the replaced items via email or fax.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) arrived unannounced to conduct a case management visit. LPA met with staff during today's visit. Case management visit regarding incident report detailing an unexpected death. LPA was able to talk with Administrator regarding R1, R1 has had multiple visits on 4/14/2025, 6/19/2025, 7/11/2025 and 7/15/2025 to the ER for UTIs and has aliments /limitation that require assistance from home health services. LPA met with the Administrator and briefly reviewed pre-assessment and support plan that was active when R1 was living. Exit interview conductedthe state’s words, verbatim · CDSS document, Sep 5, 2025

Type of visit: Case Management - Incident

"LPA Johnson arrived to the facility unannounced to conduct a case management visit based on two incident reports submitted to the department on 7/08/2025. It was reported to the department that at approximately 10:00 AM, R1 reported that after breakfast she felt fatigue. RCD checked blood pressure and was reading at 70/45. R1 reported no dizziness, no blurred vision, no confusion noted and did not want to seek further medical attention. RCD encouraged R1, but R1 refused. RCD encouraged R1 to eat salty snacks/food and will come back to check resident alter 30 minutes. RCD checked R1's blood pressure after 30 minutes with no change. R1 was encouraged again to go to the R1 agreed. 911 was called and R1 was transported to SJMC. Shanel Thitphaneth, LVN/RCD witnessed the event as reported. R1 was admitted to the hospital for observation. LPA reviewed resident's files and reviewed pertinent documentation related to this facility. As a result of this incident the resident was sent out on 7/08/2025 and has not returned. The facility will reassess R1 before she returns. Continued 911 was immediately called due to MT noting R2 with labored breathing and lips turning purple with oxygen on. RP was called and R2 was taken to St. Joseph's Medical Center for further treatment. R2 on 07/08/2025 at around 11:00 AM with admitting diagnosis of pneumothorax. RP is aware and is currently with R2 at the hospital. The facility will continue to follow-up on resident's status until her return from the hospital. No deficiencies were cited on today's visit Exit interview conducted.the state’s words, verbatim · CDSS document, Jul 14, 2025

Type of visit: Case Management - Incident

LPA Johnson arrived to the facility unannounced to conduct a case management incident report submitted to the department on 4/14/2025. It was reported to the department that at around 1:00 AM, 4/12/2025, resident reported he was trying to use his urinal and slipped out of his chair. Per resident, he hit his head on the dresser and landed on the floor, No reported dizziness, no noted injuries or bruising, Resident had complaint of mild pain to his head, Paramedics were called and transported resident to San Joaquin General Hospital. LPA reviewed resident's file and reviewed pertinent documentation related to admissions to this facility. As a result of this incident the resident was sent out on 4/12/2025 and has not returned. The facility will reassess R1 before he returns. LPA was able to obtained copies of resident's discharge summary from the skilled NF, functional assessment, service plan and other pertinent information from R1's file. No deficiencies were cited on today's visit Exit interview conducted.the state’s words, verbatim · CDSS document, Apr 23, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Albert Johnson arrived at facility and met Nellie to conduct an unannounced POC visit from the annual completed on 11/25/2024 and case management visits on 7/29/2024 and 6/07/2024. The facility submitted required corrections as required by due dates POC's corrected Deficiencies cleared Exit interviewthe state’s words, verbatim · CDSS document, Dec 11, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with G Monares (LVN) and explained the purpose of the visit. LPA inspected the physical plant with G. Monares including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 117 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. During the tour LPA observed broken ceiling panels, exposed wires and rat dropping. Fire extinguishers and smoke detectors/carbon monoxide detectors are operational. The fixed system in the kitchen is out of compliance and needs servicing. The last service date was 7/18/2023 this requires a semi-annual servicing. Citation and civil penalty assessed. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 10 resident and 5 staff files, including criminal record clearances. All staff are fingerprinted and cleared. First aid kit was checked and is complete. Deficiencies were cited pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conductedthe state’s words, verbatim · CDSS document, Nov 25, 2024

Allegation investigated: Facility does not ensure the heater is in good repair

On 10/31/2024, LPA Johnson arrived unannounced to investigate the above allegation. Based on interviews with staff on 10/31/2024, the facility is having issues with the (HVAC) heater. The parts to replace the heater have been received and the facility is actively working on fixing the heater. The facility has advised the residents of this matter and has offered to supply additional blankets and throws to comfort the residents while the heater is being repaired. The allegation is substantiated meaning that there was a preponderance of evidence to prove that the allegation occurred as alleged. An exit interview was conducted, a copy of the LIC9099, 9099-D, and appeals rights was provided to the Facility. Substantiatedthe state’s words, verbatim · CDSS document, Oct 31, 2024 · control 27-AS-20241030111610

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a)(b-1) · Plan of correction due date: Nov 1, 2024

87303 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.(b) A comfortable temperature for residents shall be maintained at all times. (1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). Based on an interview with the Staff the facility is having issues with the heater. The parts to replace the heater have been received and the facility is actively working on fixing the heater. This poses an immediate risk to the health safety of residents in care.the state’s words, verbatim · CDSS document, Oct 31, 2024

Plan of correction: Licensee will repair the HVAC system to maintain a comfortable temperature by the POC date 11/1/2024. The facilities Staff will check each residents room to ensure that the residents are comfortable during the evening and will supply additional blankets or throws if needed. The facility will send a report to the department by 11/1/2024 when the repairs have been completed.

Type of visit: Case Management - Incident

On /7/29/2024, LPA Johnson arrived unannounced to conduct a case management visit into an incident report received on 7/26/2024. The incident detailed that a Resident found a bottle of cleaning solution in the bathroom of his apartment. R1 drank half of the cleaning solution when staff intervened. He said he did it because “it was a good way out.” Poison control was called and he was transported to St. Joseph emergency room and R1 is presently being care for there. LPA reviewed resident file and obtained copies of relative information. R1 Physician's report confirmed that R1 is able to maintain his grooming and hygiene items. R1 discharge summary from St. Joseph's Behavioral health dated 2/9/2024 confirmed that R1 presented to the emergency room with suicidal Ideations and severe depression. LPA advised the facility to report all incident to the department and to provide the required information to confirm a new Administrator. Deficiencies were cited on the attached 809 D page. At the time of the visit, the issuance of a Civil Penalty was still being determined and the licensee was informed that a civil penalty might be assessed. Exit interview conducted and appeal rights given.the state’s words, verbatim · CDSS document, Jul 29, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jul 30, 2024

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. Based on observation the licensee failed to secure toxins. A cabinet in a resident bathroom contained toxins. R1 took the toxin and ingested the cleaning supplies. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 29, 2024

Plan of correction: The facility will assess residents discharge summaries for information that may have been missed. The Administrator and RCD will provide the department with a plan to review discharge paper work prior to admissions.

Type of visit: Case Management - Health Checks

On 6/13/2024, LPA Albert Johnson made an unannounced visit on this date to conduct a health and safety check. LPA met with Administrator Ignacio Lopez III. The facility must during construction ensure that during all phases of alteration to the facility, maintain the facility in compliance with Title 22 regulations. The licensee must protect the clients in care from any health and safety hazards during and/or resulting from construction. During the walk through LPA observed exposed wires not covered in the main hallways of the construction area. The construction company covered the exposed wires during the safety check today. The facility will continue to monitor the construction areas to maintain the safety of all residents including visitors during the different phases of the construction project. The department will continue to monitor the construction areas to maintain compliance and safety standards while construction is in progress. LPA was able to confirm medication control medication counts are accurate. The facility was given and advisory for taping medication back into the bubble packs after a pill has been accidentally pushed out. LPA was able to confirm that the pill taped back into the bubble pack was the same medication as the other pills by observation only. The facility will use medication destruction records when medication are destroyed. (Advisory given). Exit interview conductedthe state’s words, verbatim · CDSS document, Jun 13, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jun 13, 2024

87303 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 evidenced by observation and photos taken. During the walk through LPA observed exposed wires not covered in the main hallways of the construction area which poses an immediate health, safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 13, 2024

Plan of correction: The construction company covered the exposed wires during the safety check today. The facility will continue to monitor the construction areas to maintain the safety of all residents including visitors during the different phases of the construction project.

Type of visit: Case Management - Health Checks

On 4/25/2024, LPA Albert Johnson made an unannounced visit on this date to conduct a health and safety check along with follow-up on incident reports. LPA met with Administrator Ignacio Lopez III The temperature in the facility was a comfortable 77 degrees in the main area. There was constructions happening through out the facility. The facility had issue with six rooms which involved air conditioning. The facility has addressed these issue and is working toward replacing units and upgrading the HVAC system. The fixed system in the kitchen is out of compliance and needs servicing. The last service date was 7/18/2023 this requires a semi-annual servicing. Citation and civil penalty assessed. As a reminder the facility must during construction ensure that during all phases of alteration to the facility, maintain the facility in compliance with Title 22 regulations. The licensee must protect the clients in care from any health and safety hazards during and/or resulting from construction. Health and Safety check today included overall safety of the facility including food supply, physical plant and staffing. The facility will continue to monitor the construction areas to maintain the safety of all residents including visitors during the 2nd phase of the construction project. (Advisory given).the state’s words, verbatim · CDSS document, Jun 7, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jun 8, 2024

87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met based on: Observation, The facility failed to maintained in conformity with the regulations adopted by the State Fire Marshal. The "Fixed System" or "Ansul System" in the kitchen, this system is scheduled for a semi-annual maintenance and was last serviced on 7/19/2023the state’s words, verbatim · CDSS document, Jun 7, 2024

Plan of correction: Administrator will ensure that the fire equipment listed is inspected or a plan is made and sent to CCL by the POC date indicated. Licensee/Administrator shall send picture of the new tags as proof and submit Statement of Compliance by POC date.

Type of visit: Case Management - Incident

On 4/26/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management regarding an incident occurring on 2/16/23. LPA Jensen met with Executive Director Ignacio Lopez III and explained the purpose of today's visit. The incident was self reported. The facility reported that Resident 1 (R1) entered Resident 2's (R2) room and made unwelcome sexual advances upon R2. The incident was reported to all required entities. The police report was obtained from Stockton Police Department. R1 was interviewed and confirms he visited R2's apartment briefly to give her some sweets where he remained at the door and then left. R1 denied all sexually assaulting R2, and no visible injuries noted in the report. The Executive Director (ED)was interviewed and advised there has never been any issues or prior history involving R1 and R2. The ED confirms there has been one previous incident with R1 exposing himself; however, he was made aware that behavior was not allowed, and it was unclear if the exposure was on purpose or accidental. There is no mention of any sexualized behavior in the Needs and Services Plan for R1. Facility staff implemented a safety plan for R2, where she is to be escorted to and from her apartment and ensuring her front door is locked when she is home. R2 stated she felt safe residing at the facility and with staff caring for her. R1 was advised by law enforcement officers to no longer interact with R2 nor be near R2. Based on interviews conducted with staff present at the time of this incident, the safety plan implemented for R2 was verbal and cross reported shift to shift with no definitive terms or time frame documented. Technical assistance is being provided with a recommendation to document any such safety plan or directives given to staff to ensure the safety of residents in care. The physician's report for R1 is dated 8/15/22 and states there is no indication of inappropriate behavior. Based on the incident of 2/16/23 and a prior incident with R1 exposing himself the Department is requesting a new LIC 602 be obtained in order to determine if there any unidentified service needs and ensure R1 is compatible with this facility's population and level of care. For the purposes of this case management interviews were conducted and the following documentation was reviewed: Stockton Police Report Facility Incident Report Resident file for R1 Resident file for R2 An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 26, 2024

Type of visit: Case Management - Incident

On 4/25/2024, LPA Albert Johnson made an unannounced visit on this date to conduct a health and safety check along with follow-up on incident reports. LPA met with G. Monares and was introduced to the new Administrator Ignacio Lopez III The temperature in the facility was a comfortable 74 degrees in the main area. There was constructions happening through out the facility. As a reminder the facility must during construction ensure that during all phases of alteration to the facility, maintain the facility in compliance with Title 22 regulations. The licensee must protect the clients in care from any health and safety hazards during and/or resulting from construction. LPA observed safety signs posted and areas controlled from access. Health and Safety check today included overall safety of the facility including food supply, physical plant and staffing. The facility submitted an incident report for a medication error on 4/12/2024. The facility concluded it's own internal investigation and as a result of the medication error and investigation, S1 has been terminated and other Med-tech have received additional training in medication administration. The facility has sent out several residents for falls. All resident have returned with the exception of R1. R1 is currently at the San Joseph's Hospital and will be moving to an acute care for rehabilitation until R1 is able to return to the facility. The facility has started an new Administrator/ Executive Director. The facility has not submitted the required information to appoint Ignacio Lopez III as the new Administrator. Licensee will submit to the department the required information to appoint the new Administrator including an updated LIC500 and LIC200. Licensee will send the requested information to LPA by end of day on 04/26/2024. Today the facility was providing food service for upstairs residents in their rooms. Staffing for the day shift was adequate. No deficiencies were cited pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted.the state’s words, verbatim · CDSS document, Apr 25, 2024

Type of visit: Case Management - Health Checks

On 4/2/2024, LPA Albert Johnson made an unannounced visit on this date to conduct a health and safety check. LPA met with G. Monares. The temperature in the facility was a comfortable 74 degrees in the main area. There was constructions happening through out the facility. As a reminder the facility must during construction ensure that during all phases of alteration to the facility, maintain the facility in compliance with Title 22 regulations. The licensee must protect the clients in care from any health and safety hazards during and/or resulting from construction. For example, if the construction process presents any danger, the licensee is responsible to ensure the clients have no access to that area. LPA observed safety signs posted and areas controlled from access. Health and Safety check today included overall safety of the facility including food supply, physical plant and staffing. The facility has food service for residents in the a new location with a smaller area and uses times to allow for residents to eat their meals. Staffing for the day shift was at adequate. No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted.the state’s words, verbatim · CDSS document, Apr 2, 2024

Type of visit: POC

On 3/19/24, Licensing Program Analyst (LPA) Albert Johnson arrived at facility unannounced to clear citations for a case management visit that was completed on 2/1/2024. LPA Johnson met with Gretchen Monares and explained the purpose of today's visit. The following deficiencies, initially cited during a visit on 02/01/2024, have been cleared:the state’s words, verbatim · CDSS document, Mar 19, 2024

Allegation investigated: Licensee evicted resident without sufficient cause.

On 2/1/24 at approximately 10:00am Licensing Program Analyst (LPA) Albert Johnson arrived at facility unannounced to investigate the above listed allegation. LPA Johnson met with Gretchen Monares and explained the purpose of today's visit. Based on records reviewed LPA was able to determine that on or about 3/23/23, R1 was in a verbal and physical altercation with R2; two staff witnessed R1 pull the walker of R2 and then kicked R2. The documentation does not say where R2 was kicked. Police were not called, no SOC 341 submitted or an incident report to the department. Continued Unsubstantiated R1 denied that the incidents occurred as reported, but, confirms that the incident described in this report happened. The department has determined that the facility did not report this incident that is being identified as the reason along with other alleged incidents to deliver 30 day notices to R1. The facility was given a citation on 12/4/23 for not reporting the incident. Therefore, no citations will be given for not reporting this incident. The facility did submit the 30 day notice to the department and the notice was a legal notice that contain the required information including resources for alternative housing and assistance. Based on records reviewed and the review of the resident's 30 day notice, the preponderance of evidence standards has not been met. The allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, the preponderance of evidence standards has not been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies are being cited. Exit interview held, a copy of report given.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 27-AS-20240131083407

Allegation investigated: The heater does not work in some rooms The facility is billing for additional services without notice or updating service plans

On 2/1/24 at approximately 10:00am Licensing Program Analyst (LPA) Albert Johnson arrived at facility unannounced to investigate the above listed allegation. LPA Johnson met with Gretchen Monares and explained the purpose of today's visit. Allegation: The heater does not work in some rooms. Based on records reviewed and touring the facility the allegation is substantiated. There are several room that are without proper working units those room are 31 rooms that are not working. The rooms are not being used any residents that were in those rooms have been moved Continued Substantiated The facility provided a letter from 5/1/2023 identified as "2023 rate adjustments." This form was not signed by the residents or the responsible parties. The facility did not identify what number would constitute excessive use of tray service and failed to update the service plan to address the incur cost for tray service. R1 was billed for tray service on 4/23/23, this is the only record of this service and does not appear to be excessive. R2 was billed for tray services on 12 occasions and 2 extra dinners from 12/18/2022 to 12/16/2023, totaling $300.00 dollars. The facility did not re-access R2 to determine if there was a change in service need. The facility was made aware by R2 that Staff/Waiter in the dining room continued to have conflict with him for an extended period of time. This is documented in the care notes for R2. The facility has recently terminated the Staff that was reportedly harassing R2. The allegations are SUBSTANTIATED. A finding of substantiated means the preponderance of evidence standard has been met. Deficiencies are being cited from the California Code of Regulations (CCR) and Health and Safety Code (HSC). Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights were given.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 27-AS-20231116110730

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 15, 2024

87303 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 is not met as evidenced by records reviewed the facility has 31 rooms without working heaters. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 1, 2024

Plan of correction: The facility will repair or replace the Unit for air-conditioning and heating by the POC date or provide the department with a plan to repair or replace the unit by 2/15/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Feb 15, 2024

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by records reviewed the facility did not address the additional use of tray services for R2 from 12/2022 through 12/2023.the state’s words, verbatim · CDSS document, Feb 1, 2024

Plan of correction: The Administrator will update any and all service plans for any resident that is being billed for services not identified in their pre-appraisal or their current service plan. Proof of this will be submitted to licensing by 2/15/2024

Allegation investigated: Licensee evicted resident without sufficient cause.

On 1/19/24 at approximately 10:40am Licensing Program Analyst (LPA) Albert Johnson arrived at facility unannounced to investigate the above listed allegation. LPA Johnson met with Business Office Manager Nelle Gomez and explained the purpose of today's visit. LPA was later contacted by Gretchen Monares via phone. Based on records reviewed LPA was able to determine that on or about 10/01/22, R1 was in a physical alter with another resident; staff S1 witnessed R1 "smack and scratch R2 after R2 turned out the lights in the resident lounge." Police were not called, no SOC 341 (REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE) submitted or an incident report to the department. Unsubstantiated Again on 5/30/23 R1 rammed his wheelchair into R2 and assaulted R2 by punching him in the shoulder. R1 continued with a letter threatening to "beat R2 within inches of life." Police were not called, no SOC 341 submitted or an incident report to the department. R1 denied that the incidents occurred as reported, but, confirms that the incident described in this report, he feels that he was the victim and he was defending himself. The department has determined that the facility did not report incidents that are being identified as reasons along with other alleged incidents to deliver 30 day notices to R1. The facility was given a citation on 12/4/23 for not reporting the incidents. Therefore, no citations will be given for not reporting these incidents. The facility did submit the 30 day notice to the department and the notice was a legal notice that contain the required information including resources for alternative housing and assistance. Based on records reviewed and the review of the resident's 30 day notice, the preponderance of evidence standards has not been met. The allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, the preponderance of evidence standards has not been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies are being cited. Exit interview held, a copy of report given.the state’s words, verbatim · CDSS document, Jan 19, 2024 · control 27-AS-20240117162829

Type of visit: Case Management - Other

LPA Johnson arrived unannounced to follow-up on the 30 day notices submitted to two residents for various infractions. During the investigation the department was able to determine that there were several incidents that should have been reported to the department as well as other local authorities. The department discovered that the facility did not report incidents detailed in the notices that were given to R1 and R3 to support the decisions to have these residents move out. On or about 10/01/22, R1 was in a physical alter with another resident; staff S1 witnessed R1 "smack and scratch R2 after R2 turned out the lights in the resident lounge." Police were not called, no SOC 341 (REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE) submitted or an incident report to the department. Again on 5/30/23 R1 rammed his wheelchair into R2 and assaulted R2 by punching him in the shoulder. R1 continued with a letter threatening to "beat R2 within inches of life." Police were not called, no SOC 341 submitted or an incident report to the department. Additionally, on or about 3/23/23, R3 was in a verbal and physical altercation with R4; two staff witnessed R3 pull the walker of R4 and then kicked R4. The documentation does not say where R4 was kicked. Police were not called, no SOC 341 submitted or an incident report to the department. The department has determined that the facility did not report incidents that are being identified as reasons along with other alleged incidents to deliver 30 day notices to R1 and R3. Based on the findings the facility did not report as mandated reporter incident of assaults on more than one occasion.the state’s words, verbatim · CDSS document, Dec 4, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1) · Plan of correction due date: Dec 5, 2023

Reporting Requirements Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...any; and disposition of the case. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not submit a written incident report to Licensing as required. Resident Care Director confirmed with LPA that an incident report was not submitted for any of the identified incidents in the report for today's visit. This poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 4, 2023

Plan of correction: Licensee will have an outside agency conduct a training for Mandated reporting requirements for all staff and managers. The training schedule will be submitted to the department by the close of business on 12/5/2023. The facility will submit the list of individuals trained or the sign in sheet for the training by the plan of correction date. The facility will be responsible for finding a vendor that will conduct the training from a list of providers on the CDSS website.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with G Monares (LVN) and explained the purpose of the visit. Later joined by Zach Butcher. There was no current certified RCFE Administrator during this inspection. LPA inspected the physical plant with G. Monares including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 117 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. The bus used to transport residents does not have the required license number which is required identifying information.(Advisory given). Also observed was the elevator is out of compliance with work that is needed to get permit to operate.(Advisory given). Fire extinguishers and smoke detectors/carbon monoxide detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. During the medication review LPA and LVN observed that R1 and R2 had missed doses of medications on multiple days. LPA reviewed 15 resident and 5 staff files, including criminal record clearances. During the staff file review LPA observed a missing health screening for S1. All staff are fingerprinted and cleared. First aid kit was checked and is complete. Deficiencies were cited pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conductedthe state’s words, verbatim · CDSS document, Nov 13, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Nov 14, 2023

87405(a) All Facilities shall have a qualified and currently certified administrator. This requirement was not met as evidenced by interviews with staff.the state’s words, verbatim · CDSS document, Nov 13, 2023

Plan of correction: Licensee will submit to LPA an updated LIC500 and LIC200 with an employee who has a current administrator certificate and who will act in the administrator capacity until Licensee finds and updates the Administrator positions. Licensee will send to LPA by end of day on 11/14/2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Nov 14, 2023

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 is not met as evidenced by: Based on observation and records review, the Licensee did not ensure medications ordered for residents were given as prescribed which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2023

Plan of correction: The Administrator will developed a plan on how the facility will follow the Physician's orders and document correctly when medications are missed. Please send the agenda along with the sign-in sheet for the in-service, by POC date or give a time when the training will take place and send that information to the department The facility will also report all incidents of medication errors, missed medication Etc.. to the resident's Primary Care Physician and to the department.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(f) · Plan of correction due date: Nov 17, 2023

General. Good physical health of personnel shall be verified by a health screening, including a T.B. test, performed and signed by a physician not more than six months prior to or seven days after employment. LPA observed staff did not have a health screening and TB test results in S1's file.the state’s words, verbatim · CDSS document, Nov 13, 2023

Plan of correction: Administrator to provide a health screening/TB results for staff (S1) by POC date 11/17/2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced Case Management visit today at the facility. The department received an incident report dated 10/7/2023. The LPA reviewed records, toured the facility and interviewed the Administrator about events related to medication errors and a resident moving out. The LPA reviewed resident records, staff records and staff training records. Medications and medication procedures were also reviewed. Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were cited during this visit. Advisories given. Exit interview held and appeal rights given.the state’s words, verbatim · CDSS document, Oct 16, 2023