Oakmont Gardens

Allegation investigated: Facility is not responding to call buttons

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to open an investigation into the above allegations. LPA met with Raymond Rodarte, Business Office Manager (BOM). Upon arrival LPA requested documents. LPA learned that subject of complaint (R1) is an Independent Living (IL) resident. LPA reviewed Admissions Agreement (AA) for R1. AA for R1 is an Independent Living Residency Agreement. LPA reviewed resident roster; R1 has a care level of IL. CCL does not have jurisdiction over IL residents' care needs. LPA discussed with BOM policy of assessing residents for the need to move to Assisted Living (AL) for those needing a higher level of care. BOM advised that if the resident is observed to need a higher level of care, then that observation is discussed with the resident or responsbile party. If they choose to move to AL, the facility will accomodate that, conduct a care needs assessment, and provide a new care plan. This agency has investigated the complaint alleging facility is not responding to call buttons. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Unfoundedthe state’s words, verbatim · CDSS document, Jun 11, 2026 · control 21-AS-20260609111125

Type of visit: POC

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a POC case management visit and was greeted by concierge. LPA met with Administrator Sanjay Kabadi On 2/19/26 facility was issued a citation on substantiated complaint findings of deficiency of Health and Safety Code 1569.269 (complaint # 21-AS-20260109140715). The plan of correction required facility to: Facility to submit plan identifying why response times are delayed and the method of correction facility will implement in order to correct the delays in call button/pendant response time, by plan of correction due date. Additionally, facility to ensure that pendant/call button system is in good repair, fully operational, and staff is sufficient to timely answer pendant/call button calls, by plan of correction due date. Facility to submit paperwork of pendant/call button system implementation and log showing that pendant/call button system is in good repair and fully operational, by plan of correction due date. Plan of correction was due 3/5/26. On 3/4/26 LPA received from facility the plan identifying why response times are delayed and the method of correction facility will implement in order to correct the delays in call button/pendant response time. However, as of today, 3/10/26 CCL has not received paperwork of pendant/call button system implementation and log showing that pendant/call button system is in good repair and fully operational. Therefore, a civil penalty is being issued for failure to correct for the period of 3/6/26 through 3/10/26 at $100 per day for a total of $500. The $100 per day civil penalty will continue to accrue until the deficiency is cleared. Per Administrator, facility has decided the vendor with whom they will purchase the new pendant system but have yet to sign the contract and begin implementation. Administrator will advise LPA once implementation has been completed. Once implementation is complete, facility will immediately train staff on new system and submit log to CCL showing system is fully operational and responses are timely. Continued on 809C... Continued from 809... Additionally, LPA conducted a review of facility’s transportation policy outlined in facility’s Admission Agreement, Plan of Operation, and Emergency Disaster Plan (LIC610E). Page 6 item G in facility Admission Agreement states they will make transportation available to residents "to the nearest appropriate health facilities for medical and dental appointments, social services agencies, shopping, recreational facilities, and religious activities, as outlined in the Resident Handbook." LPA reviewed Resident Handbook. Page 31 of handbook does offer an outline of transportation services and days on which services will be available. LPA reviewed facility's Plan of Operation (POO), section VIII pertaining to transportation. This section specifies in greater detail the times and days on which transportation services will be provided. Additionally, per the Plan of Operation, all Assisted Living (AL) residents can book a ride with Lyft by contacting the concierge. The cost is paid for by the facility, initially, but then charged back to the residents on their monthly statement. LPA discussed with Administrator including in the Admissions Agreement, or the Resident Handbook, the details stated in the POO to provide residents with clarity on services and charges. LPA discussed with Administrator alternative appointment scenarios that could fall outside of the specified days and times and making transportation available. Facility has a van that is operated by staff (S1 and S2) that are licensed with a class B to drive facility van. LPA reviewed training record and driver's license class, both drivers possess class B license. Additionally, facility is in the process of getting a bus licensed for use that will be used in conjunction with the existing van. Upon LPA arrival, LPA observed van in operation. Driver was heading out, enroute to a resident medical appointment. LPA reviewed facility's Emergency Disaster Plan (LIC610E), plan does not state that drills will be conducted with residents. However, residents are provided a Resident Emergency Preparedness Guide along with their Resident Handbook. Topics covered are: Resident Preparedness, In the Event of a Fire, Wildfire, Power Outage, Earthquake, Preparedness checklist, and Contacts. Guide does not state drills will be conducted with residents. On page 6 of guide, under "Community Basics to Know/Staffing," it states that "we conduct fire drills on a monthly basis, elopement drills...on a quarterly basis, and larger fire drills on an annual basis. Continued on 809C(2)... Continued from 809C... During these drills residents should react as though the situation is real and respond by following the appropriate steps as laid out in this guide." One could infer that residents are to be a part of the drills, but the guide does not expressly state as such. LPA discussed with Admin adding clarification to guide to remove any ambiguity. On page 7 of guide under "Onsite Designated Evacuation Assembly Sites," the location of evacuation sites are listed. Per Scott Doherty, V.P. Senior District Operations Manager (DOM), facility is currently updating their emergency disaster plan via a consultant. DOM reported to LPA that the consultant is helping the facility organize a community wide evacuation drill. Per DOM, consultant will speak with the residents within the next two weeks. This consultant will also help the on site operations team to update the community emergency procedure manual and the consultant will be helping the operations team to organize a community wide evacuation drill. Per DOM, the community also has scheduled representatives from the local fire department to come to the community to speak with the residents next week. Per LPA review of these documents, LPA finds facility to be following their plan of operation and Admissions Agreement. However, there is room for clarity as discussed with Administrator. LPA observed Emergency Disaster Plan to need updating as previous Health and Wellness Director and previous Administrator are listed under assignments of duties. Administrator will submit updated plan no later than April 1, 2026. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Mar 10, 2026

Allegation investigated: Facility does not meet resident needs Facility is not responding to call buttons

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings for the above allegations. Administrator (Admin) Sanjay Kabadi was not available to come to the facility but was available by phone. LPA spoke to Admin and let him know the purpose of LPA's visit and let him know the findings. LPA met with Raymond Rodarte, Business Office Manager (BOM). Complaint alleges facility does not meet resident needs and facility is not responding to call buttons. During investigation, LPA reviewed pendant call logs. LPA reviewed logs for the time period of 12/14/25 through 1/15/26. Within these dates residents pressed their call button/pendant approximately 1541 times. Of the approximate 1541 times the wait time until someone responded was: 10 minutes or greater: 717 times 20 minutes or greater: 170 times Continued on 9099C... Substantiated Continued from 9099... 30 minutes or greater: 130 times; one occurrence of a smoke detector for 32 minutes. 40 minutes or greater: 40 times 50 minutes or greater: 24 times 60 minutes or greater: 20 times 70 minutes or greater: 15 times 80 minutes or greater: 18 times 90 minutes or greater: 12 times 100 minutes or greater: 15 times 150 minutes or greater: 3 times The longest wait times were single occurrences of: • 165 minutes, • 193 minutes, • 225 minutes, • 309 minutes, • 334 minutes, • 390 minutes, • 429 minutes. Of the approximate 1541 times a resident pushed their pendant 1172 of those times their wait was longer than 10 minutes, which is approximately 76% of the time. During investigation, LPA interviewed five [5] residents with wait times longer than 50 minutes. Five [5] out of five [5] residents interviewed confirmed they waited at least 50 minutes before anyone arrived to answer their call for assistance. One resident (R1) reported that a care staff arrived to answer the pendant call but then reset the pendant and immediately walked out, without asking them if they needed assistance or providing any help. Two residents (R2 and R3) reported that, at times, no care staff show up at all. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Exit interview conducted with BOM. Appeal rights and a copy of this report given.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 21-AS-20260109140715

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269 · Plan of correction due date: Mar 5, 2026

§1569.269 Enumerated rights... a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs...This requirement not met by licensee as evidenced by: Based on LPA record review of facility's pendant/call button system log, the licensee did not comply with the section cited above in that between 12/14/25 and 1/15/26 residents pushed their pendant call button at least 1541 times. Of those 1541 times, residents waited over 50 minutes at least 114 times, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: Facility to submit plan identifying why response times are delayed and the method of correction facility will implement in order to correct the delays in call button/pendant response time, by plan of correction due date. Additionally, facility to ensure that pendant/call button system is in good repair, fully operational, and staff is sufficient to timely answer pendant/call button calls, by plan of correction due date. Facility to submit paperwork of pendant/call button system implemetation and log showing that pendant/call button system is in good repair and fully operational, by plan of correction due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Sanjay Kabadi, Administrator certificate #7012609740 expires 8/16/26. At approximately 9:30am LPA and Head of Maintenance (HOM) toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food items such as ice cream, rice, bread, tortillas, chopped onions, chopped tomatoes, prepared steaks, and chopped greens were all found uncovered and/or in open unsealed bags/bins (deficiency cited, see 809D). Two gallons of milk located in ancillary kitchen refrigerator did not have dates of opening, LPA discussed with Admin ensuring all opened items be labeled with date of opening. Facility was in the middle of a buffet lunch while LPA was touring kitchen. Bun rack containing steaks and other food items were not covered. Kitchen staff explained steaks were resting and that is why they were uncovered. LPA advised that the bun rack itself should have a cover that covers the entire rack. LPA and HOM observed disinfectants and cleaning solutions in unlocked cabinet in ancillary Assisted Living Dining room (deficiency cited, see 809D and civil penalty assessed see LIC421FC). Main kitchen disposal sink has an active leak and hot box door does not properly latch or seal shut (deficiency cited, see 809D). Water in main kitchen measured at 126.5 degrees F, so LPA and Admin discussed putting up warning signs of water temperature over 125 degrees F. Facility has Independent Living (IL) and Assisted Living (AL) residents. Facility does not offer Memory Care. LPA toured selected AL resident rooms: #159, #155, and #161. All apartment bathrooms were equipped with an emergency pull cord and grab bars. Water temperature in sink accessible to residents in care measured at Continued on 809C... Continued from 809... 116.4 degrees F in room #159, 114.7 degrees F in room #155, and 117.1 degrees F in room #161, which are within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 12/7/24, per HOM fire extinguishers getting serviced within the week. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired, last serviced by vendor in February 2025. Facility’s last quarterly disaster drill was conducted 12/4/25. Facility equipped with four (4) elevators, permits have expired in #2 and #3 as of June 2024 and in #4 as of May 2025. Administrator to follow up with State of California Department of Industrial (DIR) Relations on getting permits current. At approximately 1:30pm LPA conducted a review of seven (7) resident records. R1, R2, R3, and R4 do not have current physician's reports on file (deficiency cited, see 809D). Additionally, R1 did not have TB clearance on file. At approximately 2:00pm LPA conducted review of seven (7) staff files. All seven (7) staff did not have Health Screens on file (deficiency cited, see 809D). Two (2) out of seven (7) staff (S5 and S6) did not have any 1st Aid/CPR on file (deficiency cited, see 809D). At approximately 4:00pm LPA and Med Tech conducted a spot check of medication and medication records. Medication is centrally stored in a locked room. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308 Designation of Facility Responsibility Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Dec 11, 2025

The state marks this report as 9 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: POC

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to conduct a Case Management visit. LPA was greeted by concierge. Sanjay Kabadi, Administrator was unavailable but greeted LPA later. On 7/17/25 LPA issued citations for deficiencies of regulations: Health and Safety Code (HSC)1569.269(a)(6), CCR 87465(h)(5), and CCR 87465(a)(4). The plan of correction for HSC1569.269(a)(6) required facility to submit plan to CCL to conduct personal rights training and training for all direct care staff on prompt call/pendant response times by plan of correction due date. Training to be conducted through facility's chosen vendor, Relias as well as an in-service training by no later than 8/7/25. The plans of correction for deficiencies of CCR 87465(h)(5) and 87465(a)(4) required facility to submit plan to conduct in-service training on pre-pouring medication and medication administration training by plan of correction due date. In-service training to be conducted no later than 8/7/25. Additionally, facility to submit written procedure plan to conduct daily audit of medication closet and medication cart to ensure staff are not pre-pouring medications, by no later than 8/7/25. On 7/18/25, Health Services Assistant (HSA) Pam Brown submitted required plans for these deficiencies. However, as of today, CCL has not received the in-service training logs nor the Relias training records required for the plan of correction. So, these deficiencies are being re-cited today (deficiencies cited, see 809D). During visit, LPA found medication room unattended, unlocked, and with medication bubble pack accessible to residents (deficiency cited, see 809D). Continued on 809C... Continued from 809... LPA also observed Centrally Stored Medication closet to contain a rainbow medi-set pillbox with medications present, giving the appearance of pre-pouring. Per LPA interview with Jody Livingston, Health and Wellness director (HWD) facility has stopped pre-pouring. She explained that the medications found were not pre-poured but rather were medications given to the facility by a resident. The pillbox was waiting to be destroyed because the pills were not labeled and it is Oakmont Gardens' policy that any medication not in a pharmacy bottle is not acceptable. HWD emphasized to LPA that in her view, the medication pillbox was not in rotation and was in the overflow section of the medication closet such that they would not be confused with any medications being given to residents. No citation issued today; however, LPA discussed with HWD facility's compliance history with pre-pouring medications and that today's appearance of pre-pouring is out of compliance with regulation. LPA advised that all medications needing to be destroyed should be destroyed immediately. HWD agreed and expressed to LPA that going forward all medications needing to be destroyed will be destroyed immediately. Additionally, during visit, LPA observed black and white fuzzy substance inside exposed walls in hallway by rooms #113-#116 which appears wet, dark in color, and has the odor of mildew. Insides of walls are exposed as well as some portions of the ceiling, exposing pipes in the wall and in the ceiling. Holes in wall were observed to be on the corner of the hallway by room#116, in the ceiling by room #116 and at the end of the hallway by room #113. Exposed portions of walls are covered by a thin clear piece of film held up by pieces of tape. Exposed portions of ceiling are not covered. LPA observed odor of mildew to be strongest at the end of the hallway by room #113. Black and white fuzzy substance that appears wet and dark in color and has the odor of mildew is accessible to residents and film covering hole does not appear to mitigate any potential airborne health hazards. LPA observed exposed inner portion of wall on the corner by room #116 to have discoloration coming from the appearance of recently being covered with paint (deficiency cited, see 809D). LPA spoke to Asst Maintenance person (S1), who explained to LPA that when railing was installed in this hallway whomever did the installation must have damaged the pipes in the wall in that location because beginning Thursday, 8/29/25 moisture was noticeably collecting and pooling at the bottom of the wall. Once the moisture was observed, facility maintenance cut open the wall to find the leaking pipes, as well as the ceiling. The leak was found and now facility is waiting for plumber to arrive and fix the leaks. Continued on 809C(2)... Continued from 809C... While at facility, LPA also followed up on Incident Reports submitted to CCL on 8/29/25 for residents R1, R2, and R3, each of these residents had experienced a fall but refused emergency medical services (EMS). Incident Report for R1, indicated R1 complained of headache but denied hitting their head, R2 was found on the floor face down but also denied hitting their head, and R3 stated they did hit their head. However, each of these residents refused EMS. LPA discussed incidents with HWD. LPA discussed the importance of getting potential head injuries assessed by a medical professional. LPA explained that it is aresident's right to refuse EMS, but the facility must document each instance of resident refusal. HWD advised LPA that facility does document all resident refusals for EMS. However, HWD could not produce documented refusals for LPA. LPA also discussed with HWD that if a resident has a behavioral expression of cognitive impairment, then best practices are that EMS should be called to assess resident. Additionally, if a residents' family member expresses their wish for EMS not to be called, to maintain compliance with regulation, facility is required to call EMS. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Sep 4, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(5) · Plan of correction due date: Sep 5, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement not met by licensee as evidenced by: Based on LPA and HWD interview, staff are pre-pouring medications, resulting in medication errors, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: Facility to submit plan to conduct in-service training on pre-pouring medication by plan of correction due date 9/5/25. In-service training to be coinducted no later than 9/18/25. Additionally, facility to submit written procedure plan to conduct daily audit of medication closet and medication cart to ensure staff are not pre-pouring medications, by no later than 9/18/25.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(a)(4) · Plan of correction due date: Sep 5, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed...(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: residents R1, R2, R3, R4, R5, R6, and R7 were each administered the wrong medication, which poses an immediate health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: Facility to submit plan to conduct 4 hours of medication training via their chosen vendor, Relias by plan of correction due date 9/5/25. Training to be completed by all staff administering medications by no later than 9/18/25.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Sep 5, 2025

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs... This requirement not met by licensee as evidenced by: R1 waited in excess of 33 minutes for staff response after activating pendant alert for assistance, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: Facility will submit plan to CCL to conduct personal rights training and training for all direct care staff on prompt call/pendant repsonse times by plan of correction due date 9/5/25. Training to be conducted through facility's chosen vendor, Relias as well as an in-service training by no later than 9/18/25.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Sep 5, 2025

(h)The following requirements shall apply to medications which are centrally stored: (2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication This requirement not met by licensee as evidenced by: based on LPA observation medication room left unattended, door unlocked, and with medications accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: Facility to submit plan to conduct in-service medication training focused on proper storage of medications and ensuring inaccessibility of medication by plan of correction due date 9/5/25. Training to be completed by all staff administering medications by no later than 9/18/25.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Sep 5, 2025

(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 not met by licensee as evidenced by: Based on LPA observation, black and white fuzzy substance that appears wet and dark in color and has the odor of mildew, found inside exposed walls in hallway by rooms #113-#116, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: Facility to submit written plan of how facility will ensure the health and safety of residents that are exposed to hallway that has exposed inner parts of wall that has black and white fuzzy substance that appears wet and dark in color and has the odor of mildew, by plan of correctiond due date. LPA will review plan and if plan is in compliance with regulation, then facility will implement plan and have plan completed no later than 9/18/25

Allegation investigated: Staff did not respond to resident's request for assistance in a timely manner.

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to open an investigation into the above allegations. Complaint alleges staff did not respond to resident's request for assistance in a timely manner. Complainant states that resident (R1) waited for more than thirty [30] minutes after pushing their pendant before staff responded to pendant call. During investigation, LPA reviewed facility's pendant call log. Call log review shows that on 7/1/25 R1 waited 17 minutes after pressing their pendant before receiveing assistance, on 7/4/25 they waited 33 minutes, in the afternoon on 7/6/25 they waited 19.5 minutes, and in the evening on 7/6/25 they waited 15 minutes. During investigation, LPA reviewed facility's call light/pendant procedure policy. Policy states that all pendant calls will be answered promptly. Policy further states that "promptness is essential, as a resident may be alone and in an emergency situation." Continued on 9099C... Substantiated Continued from 9099... Per Health and Wellness Director (HWD), Jody Livingston, Health Services Assistant (HSA) Pam Brown, and Business Operations Manager (BOM), Tristan Amari, a prompt response is considered to be within 10 minutes or less. So, based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with BOM. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with BOM and a copy of this report was given.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 21-AS-20250714151540

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Jul 18, 2025

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs... This requirement not met by licensee as evidenced by: R1 waited in excess of 33 minutes for staff response after activating pendant alert for assistance, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: Facility will submit plan to CCL to conduct personal rights training and training for all direct care staff on prompt call/pendant repsonse times by plan of correction due date. Training to be conducted through facility's chosen vendor, Relias as well as an in-service training by no later than 8/7/25.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to conduct a Case Management visit. LPA was greeted by concierge. Tristan Amari, Business Office Manager arrived later. On 7/10/25 CCL received an Incident Report indicating that facility had experienced a medication error for seven [7] residents on Monday, 7/7/25 (deficiency cited, see 809D). Later the same day, CCL received another Incident Report indicating a resident (R8) may have also received the wrong medication on 7/7/25. LPA interviewed Health and Wellness Director (HWD) Jody Livingston and Health Services Assistant (HSA) Pam Brown about medication errors that occurred on 7/7/25. Per HWD and HSA, the medications errors occurred due to Med Techs pre-pouring medication. As pertains to this incident there were two instances of pre-pouring (deficiency cited, see 809D). On the morning of 7/6/25, staff (S1) pre-poured medications to be administered on the morning of 7/7/25. On the evening of 7/6/25, staff (S2) pre-poured medications to be administered the evening of 7/7/25. The two [2] boxes of pre-poured medications were then placed in the medication closet, to be administered the next day. On the morning of 7/7/25, staff (S3) mistakenly pulled the evening medication box and administered evening medications to residents R1, R2, R3, R4, R5, R6, and R7. Later in the morning of 7/7/25, HSA was notified that resident R8 was not given her medications at all that morning. HSA then went to R8's room and administered their morning medications. So, R8 did receive her morning medications on the morning of 7/7/25; thereby receiving them at approximately 10:30am instead of at 8:00am as scheduled. Continued on 809C... Continued from 809C... Per incident report and submission of proof of notification to LPA, HWD notified each respective residents' primary care physician, via fax of respective residents' medication error. HWD notified respective residents' responsible parties via telephone. LPA advised going forward, facility to ensure responsible parties are notified in writing in addition to via telephone. Per HWD and HSA, pre-pouring as been an on-going issue with facility Med Techs. HWD knows that regulation states that each resident's medication shall be stored in its originally received container and no medications shall be transferred between containers. HWD advised LPA they stress to staff not to pre-pour medications, but that some Med Techs report pre-pouring to be much easier than live pouring. HWD advised LPA that S3 is currently on suspension and will be terminated. HWD advised LPA that additional Relias training will be conducted with all direct care staff that administer medication. In order to stress the importance of live pouring, HWD and HSA will formulate a Med Tech test based on training requirements specified in Health and Safety Code (HSC)1569.69(a)(5) for all Med Techs. HWD will send copy of prospective test to CCL before administering test to ensure compliance with HSC. Additionally, HWD and HSA have scheduled a staff meeting to address pre-pouring. HWD will address the pre-pouring by eliminating the medication boxes in which the medications are pre-poured, thereby eliminating the ability to pre-pour. Per HSA, HSA will be auditing medication room closet and medication cart to see if they find any pre-pouring. The audit will occur daily and randomly anywhere between 9:00am and 5:30pm, which covers both shifts on which medications are administered. If HSA finds instances of pre-pouring, identified staff will immediately be given a write up that is last and final. Additionally, identified staff would face discipline up to and including termination. HWD advised LPA, facility is going to re-educate staff on the logistics of giving medications, such as reviewing proper medication cart placement and procedures. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with BOM. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with BOM and a copy of this report was given.the state’s words, verbatim · CDSS document, Jul 17, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(5) · Plan of correction due date: Jul 18, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement not met by licensee as evidenced by: Based on LPA and HWD interview, staff are pre-pouring medications, resulting in medication errors, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: Facility to submit plan to conduct in-service training on pre-pouring medication by plan of correction due date. In-service training to be coinducted no later than 8/7/25. Additinally, facility to submit written procedure plan to coinduct daily audit of meication closet and medication cart to ensure staff are not pre-pouring medications, by no later than 8/7/25.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(a)(4) · Plan of correction due date: Jul 17, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed...(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: residents R1, R2, R3, R4, R5, R6, and R7 were each administered the wrong medication, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: Facility to submit plan to conduct medication training via their chosen vendor, Relias by plan of correction due date. Training to be completed by all staff administering medications by no later than 8/7/25.

Allegation investigated: Facility water turned off, resulting in residents not provided drinking water or water for toilets and bathing

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to open an investigation into the above allegations. Complaint alleges facility water was turned off, resulting in residents not provided drinking water or water for toilets and bathing. On 5/12/25 LPA was notified that a water pipe at the facility had broken and the water was shut off as of Sunday 5/11/25 from 11:00am onward and was attempted to be repaired. Facility turned the water back on Monday 5/12/25 at 10:30am, but the repair fix did not work and the repair burst. So, the water was again shut off for the entire facility. Facility did not notify CCL of water being shut off. On 5/12/25, upon learning of the incident, LPA immediately contacted facility Administrator Mark Strohschein to inquire as to status of water at facility and if they had engaged their Emergency Disaster Plan. On 5/12/25 at 2:38pm Admin responded to LPA, confirming the water had been turned off due to a Continued on 9099C... Substantiated Continued from 9099... pipe bursting and had yet to be repaired; Admin indicated to LPA that the water had not yet been turned back on, but facility had made an initial delivery of bottled water to residents’ rooms and residents would have access to restrooms across the street at Oakmont Village Community Center. Admin email to LPA also indicated staff were going to begin taking buckets of water to each apartment to flush toilets. Additionally, Admin reported to LPA pipe repair was still in process. Email to LPA from Tristan Amari, Business Office Manager (BOM) indicated Port-a-Potties whad been ordered earlier in the day and arrived around 6:00pm to the facility. Later in the evening on 5/12/25, BOM email to CCL reported facility water was fully functional and turned back on in full capacity for all residents at 8:30pm. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with BOM. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with BOM and a copy of this report was given. **On 5/13/25 LPA conducted a Health and Wellness check at facility regarding the incident that is the subject of this complaint. LPA found water to be fully operational. LPA stressed to facility that facility must report to CCL any incident which is a health and safety risk for residents. Per regulation 87211(a)(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.the state’s words, verbatim · CDSS document, Jun 10, 2025 · control 21-AS-20250604125611

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jun 11, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met by licensee as evidenced by: facility water shut off for more than 24hrs without immediately providing for residents needs that require access to running water like bathing and flushing toilets, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 10, 2025

Plan of correction: Facility to self-certify that in all cases of major occurances which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. Additionally, facility to self-certify that in such occurances facility will engage in their emergency disater plan ensuring that all residents are afforded their personal rights as outlined in regulation. Facility to submit self-certification on LIC9098 to CCL by plan of correction due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management visit and met with Tristan Amari, Business Office Manager (BOM). On 5/14/25 CCL received an Incident Report for resident R1. Incident report indicated that when staff was arriving to work for their shift they found R1 next door to facility in the Wells Fargo parking lot walking around by themselves. Staff accompanied R1 back to facility. R1 was assessed for injury and was found to be without an injury as well as appropriately dressed. LPA reviewed Physician's Report and Care Plan for R1. Per R1's physician's report, R1 is not able to leave the facility unassisted. Per R1's care plan, R1 is a wandering/elopement risk. Per Jody Livingston, Health and Wellness Director, R1 had a Wander Guard that was found to be not working. Facility contacted Wander Guard and ordered "activation wands" to be overnighted to facility. Additionally, after the incident of elopement on 5/14 facility provided 1:1 care for R1 when private caregiver or family was not present. However, as of today, per HWD, R1 is no longer a resident at the facility. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with BOM. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with BOM and a copy of this report was given.the state’s words, verbatim · CDSS document, Jun 10, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(d) · Plan of correction due date: Jun 11, 2025

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement... This requriement not met by licensee as evidenced by: R1 eloped from facility and was found alone outside of facility property, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 10, 2025

Plan of correction: Facility to submit plan to conduct in-service staff training on elopment prevention and procedures. In-service training to be conducted for all direct care staff by no later than 7/1/25.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Health and Wellness check. LPA met with Jody Livingston, Health and Wellness Director (HWD). On 5/12/25 CCL received notification that a water pipe at the facility had broken and the water was shut off as of Sunday 5/11/25 from 11:00am onward and was attempted to be repaired. Facility attempted to turn the water, back on Monday 5/12/25 at 10:30am but the repair fix did not work and the repair burst. Once again the water was shut off for the entire facility and luxury Port-a-Potties were ordered and arrived around 6:00pm to the facility. Per Tristan Amari, Business Office Manager email to CCL facility water was fully functional and turned back on in full capacity for all residents at 8:30pm. Today, at approximately 4:15pm LPA arrived to check if water was fully functioning at facility. LPA tested water in visitor's bathroom next to lobby and found it working and toilets flushing. LPA also tested water at bistro in lobby and found it fully functional. Per HWD all residents toilets are fully functioning and all residents have access to water. No citations issued during this visit. However, LPA stressed to the HWD that facility must report to CCL any incident which is a health and safety risk for residents. Per regulation 87211(a)(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. Exit interview conducted with HWD and a copy of this report was given.the state’s words, verbatim · CDSS document, May 13, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management visit and was greeted by Gloria Albor, Business Operations Manager (BOM). On 1/31/25 the facility submitted to CCL an Incident Report for resident (R1) indicating that on January 30, 2025 R1 was found on the floor in their room by caregiver and Med Tech. R1 was found to be breathing hard, presented as confused, and observed to have a bump on their head. Emergency Medical Services called and R1 was transported to the hospital emergency room. Facility reported that facility later received an email from resident's family member that R1 had passed away. Cause was unknown at the time. Facility Administrator, Morgan Holien was not available at time of LPA visit. Health and Wellness Director (HWD), Jody Livingston also not available. LPA unable to gain clarification on the cause of death of R1 as Admin and HWD were not available. LPA requested documents for R1 from BOM: Care Plan, Charting Notes, and most current physician's report. BOM does not have access to R1's documents so LPA requested facility send them to CCL by Monday, February 10,2025. No deficiencies cited.the state’s words, verbatim · CDSS document, Feb 7, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Morgan Holien Administrator Certificate 6064643740 expires 3/25/26. At approximately 9:30am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. In addition to open items being covered, LPA discussed with Admin that all opened items should also be labeled with date of opening. LPA and Admin observed disinfectants and cleaning solutions in unlocked cabinet in ancillary Assisted Living Dining room (deficiency cited, see 809D). Hot water temperature was within regulation at 123.6 degrees F; however, LPA, chef, and Admin discussed putting up warning signs of water temperature over 125 degrees F as a precaution. Facility has Independent Living (IL) and Assisted Living (AL) residents. Facility does not offer Memory Care. LPA toured selected AL resident rooms: #149, #151, and #161. All bedroom bathrooms were equipped with an emergency pull cord and grab bars. Water temperature in sink accessible to residents in care measured at 116.2 degrees F in room #149, 113.8 degrees F in room #151, and 117.1 degrees F in room #161, which are within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 12/7/24. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired, last serviced by vendor on 10/29/24. Facility’s last quarterly disaster drill was conducted 11/26/24. Facility equipped with elevators, last service date 5/2/24. Continued on 809C... Continued from 809... At approximately 11:00am LPA conducted a review of 6 resident records. No deficiencies. At approximately 12:00pm LPA conducted review of 5 staff records. Five [5] out of five [5] staff (S3, S4, S5, S6, and S7) did not have the required hours of training completed (deficiency cited, see 809D). Three [3] out of five [5] of the reviewed staff files were the files of employees assisting residents with self-administration of medication. LPA and Admin discussed Health and Safety Code (HSC) 1569.69 which covers employees assisting residents with self-administration of medication training requirements. LPA and Admin discussed the medication test referenced in the HSC that is required for all those employees assisting residents with self-administration of medication. Four [4] out of five [5] staff (S3, S4, S5, and S6) did not have 1st Aid/CPR on file (deficiency cited, see 809D) LPA and Admin reviewed Guardian roster in comparison to current staff roster. Two [2] staff members (S1 and S2) were found to not have fingerprint clearance (deficiency cited, see 809D). At approximately 3:00pm LPA and Health and Wellness Director (HWD) conducted a spot check of medication and medication records. Medication is centrally stored in a locked room. No deficiencies. LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Jan 14, 2025

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Facility not maintained in safe condition for residents

At approximately 12:45PM, Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver finding for above allegation. LPA met with Administrator Morgan Holien. Complaint alleges facility not maintained in safe condition for residents. Complainant states that the sidewalk concrete on the corner of the west entrance by WellsFargo is cracked and raised, presenting a safety hazard for residents. Complaintant states that the sidewalk concrete behind apartments #124-126 is also cracked and raised, presenting a safety hazard for residents. Complainant states that repairs to these areas have not been completed because the facility does not have enough money in their budget to fix them. During investigation, LPA contacted the City of Santa Rosa Public Works Department to determine the party responsible for the repairs, LPA was advised that private property owners are responsible for sidewalk repairs Continued on 9099C... Unsubstantiated continued form 9099... within their property lines and for areas adjacent to their property up to where the asphalt touches the bordering public road. During investigation, LPA interviewed Administrator (Admin). Admin advised that facility is aware of the sidewalk issue and has been actively working on getting bids to complete the repairs for both the sidewalk on the corner and the sidewalk behind apartments 124 and 126. Admin could not provide approximate date of when the facility became aware of the sidewalk needing repair. However, Admin provided most recent project bid from construction company (I1) dated 9/25/2024. Admin explained that the sidewalk repair project is being managed by licensee's project manager S1. During investigation, LPA interviewed S1. S1 provided LPA with proof that S1 was notified by Oakmont Gardens' Director of Maintenance (S2) on 7/8/2024 of sidewalk repairs needed. Per S1, Oakmont Gardens first inquired with the City of Santa Rosa to find out the responsible party for the repairs, be it the city of Santa Rosa or Oakmont Gardens. Once clarification was obtained, S1 set out to find a company to complete the repairs and obtain any permits needed, should they be required. S1 contacted several companies but found that most declined to provide a bid due to the small size of the project. The search for a company to accept the repair project yielded a result in September of 2024. On 9/23/24 a bid was provided by I1. On 9/25/24 S1 asked I1 to revise the bid in order to expedite completion the repairs. On 9/30/24 Oakmont Gardens approved the revised estimate. On 10/15/24, I1 communicated to S1 that application for the necessary permits was completed and the required traffic control plans were submitted. The repairs are projected to begin just as soon is the permit is issued. The City of Santa Rosa estimates a 4-6 week processing time for the permit. LPA observed I1's estimate to have an expiration date of 10/25/24. LPA asked I1 about estimate expiration date, I1 advised that the estimate is extended until the permit is obtained, "we don't want to punish our client because the city is back logged." During investigation, LPA interviewed R1, member of the Resident Council of Oakmont Gardens. R1 advised that the sidewalk repair issue was first brought to management in July or August of 2024. R1 advised that the response from management at that time was that they are shopping bids from 2-3 companies but something Continued on 9099C(2)... Continued form 9099C... will be done about it soon. R1 advised LPA that the sidewalk repair issues were discussed during the Resident Council meeting in September, then subsequently at the October council meeting. R1 advised LPA that management was both responsive, and explanatory, in reaction to the sidewalk repair concerns when they were brought up in September. Admin explained to R1 that Oakmont Gardens had been actively looking for a company to accept the project. Admin explained to LPA that Oakmont Gardens has tried to address the sidewalk issue behind apartments 124-126 by shaving down the concrete to try and level the surface, in order to mitigate any tripping hazard. LPA observed the sidewalk concrete behind apartments 124-126 to have been shaved down as evidenced by the marks in the concrete the shaver left behind. While LPA was present, Admin and S2 painted the sidewalk area behind apartments 124-126 with paint and put a sign out as a visual warning for residents, indicating presence of the uneven concrete. Admin and S2 also put a sign out on the corner sidewalk area as well, to act as visual warning. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Nov 7, 2024 · control 21-AS-20241031093432

Type of visit: Case Management - Incident

At approximately 12:15pm, Licensing Program Analyst (LPA) Christi Coppo arrived announced to conduct a case management visit in regards to an incident report submitted to CCL on 7/19/2024. On 7/19/2024 the facility submitted to CCL an Incident report indicating a medication error had occurred at the facility. On 7/16/2024, facility began helping R1 with self-administration of medications. Incident report explains that at approximately 1:30am on 7/18/2024 resident (R1) reported to NOC shift caregiver (S1) needing their PRN pain medication. R1 has a physician's order for PRN Tramadol and scheduled Gabapentin. At this time, a Medication Technician (Med Tech) was not on schedule for the NOC shift, so S1 located the medication from the medication cart and provided it to R1. At approximately 6:00am, S1 reported to the oncoming day shift Med Tech (S2) that they had provided R1 with their PRN Tramadol and their scheduled Gabapentin. S2 immediately report the incident to Health and Wellness Director (HWD). HWD then notified R1's responsible party and advised them of the incident. HWD also contacted Kaiser help line and left a message for R1's doctor. HWD left message for doctor and also sent over a fax indicating R1's medication error and inquiring as to a possible change in medication timing. Per R1's responsible party, the doctor was supposed to change the Gabapentin prescription from being scheduled every 4 hours to every 6 hours. HWD requested R1's responsible party to also follow up with doctor as HWD had not received a response back or call back from R1's doctor. R1 did not exhibit any adverse reactions from the 1:30am dose of the PRN Tramadol and Gabapentin. Per R1's responsible party, the resident was believed to be self-administering the Gabapentin during these early morning hours prior to facility's start of helping R1 with their medication. LPA confirmed R1 still has not exhibited any adverse reactions stemming from medication error. Continued on 809C... Continued form 809... Per LPA interview with HWD, S1 was terminated on 7/19/2024. Facility did not place R1 on 72 hour monitoring because the medications given were within the parameters of the physician's orders. Facility change their scheduling of Med Techs in response to this incident. Facility now has a Med Tech assigned to each shift, including NOC shift. If for any reason a Med Tech is not available to work their shift, then HWD is committed to covering the needed shift in order to ensure that someone is attending to medications 24 hours per day. Facility conducted training with staff caregivers and had them sign a form indicating that they are not to administer medication for any resident, at any time, for any reason. In addition to the training conducted with caregivers, facility also conducted training with staff Med Techs and had them sign a form indicating that they are aware of the medication policy and procedures. As an extra precaution, HWD is currently in the process of redesigning medication room for improved safety and to mitigate medication errors. HWD provided training logs and acknowledgements to LPA during case management. Additionally, HWD conduct audit of medication counts to verify all medications administered match current medication counts.the state’s words, verbatim · CDSS document, Aug 9, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 19, 2024

Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: Based on facility's submitted incident report reporting medication error, which poses an immediate health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Aug 9, 2024

Plan of correction: Facility terminated S1. Facility conducted staff training. Deficiency cleared.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management and was greeted by Morgan Holien, Administrator. On 5/8/2024 CCL received from facility a SOC341 report of abuse, type of abuse reported is physical abuse. Suspected abuser is unknown. On 5/1/2024, resident (R1) reported to Health and Wellness Director (HWD) that they were touched under the covers while sleeping. R1 reported that the suspect entered their room, and was touching them under the covers, making them feel uncomfortable. R1 stated they did not know the abuser but thinks the abuser delivers things to their room. R1 reported to HWD that it was not one of the current employees, that they know of, because the current employees do not match the physical description of the suspected abuser. R1 was upset and crying to HWD as they reported the abuse, but claimed the abuser did not sexually assault them. HWD immediately notified Santa Rosa Police Department by calling 911 to report the incident (Event #SR241220238). HWD also reported incident to LTCO. Per LPA interview with Admin, after HWD called 911 they then notified Admin of R1's report of abuse. While meeting with Admin, HWD received an email from R1's family member. Upon calling R1's family member, HWD was informed that R1 had told the family member that R1 had reported the incident to HWD. R1's family member refused to have the police come out. The police then contacted R1 on 5/2/2024 by telephone to conduct interview. Per Admin, R1 does not have a diagnosis of dementia or MCI, but does occasionally experience some issues with cognitive function. Per LPA interview with Admin, facility conducted an internal investigation on 5/1/2024 and 5/2/2024 with a subsequent follow up with staff on 5/6/2024. The facility's investigation yielded a finding of unsubstantiated. LPA confirmed with HWD R1 is now on frequent checks to monitor mental health and overall comfort. No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, May 9, 2024

Type of visit: Office

Regional Manager Carla Nuti-Martinez, Licensing Program Manager Victoria Bertozzi, and Licensing Program Analyst Christi Coppo met with Director of Operations, Ryan Excline and Executive Director, Morgan Holien, Joel Goldman Attorney in the Santa Rosa Regional office for the purpose of an informal office meeting to discuss facility's on-going lack of Administrator. Greg Williams joined via Microsoft Teams. Licensing staff discussed with facility the requirement of having a qualified administrator in the facility. Based on discussion, the current Executive Director will be completing the Administrator Certification in the next week and agrees to submit proof of items sent to LPA. Facility has provided documents to change the Administrator until the Executive Director has an active Administrator Certificate. Facility will submit a written plan outlining the duties of the Executive Director and the Acting Administrator along with other referenced items to LPA. No deficiencies cited.the state’s words, verbatim · CDSS document, Mar 1, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to continue the required Annual inspection and was greeted by Morgan Holien, Executive Director (ED). Facility currently has one resident on hospice. During initial annual inspection on 1/11/2024, LPA initiated file review at 3:00pm. LPA reviewed 5 resident files. Per LPA interview with ED and HWD, one resident is currently on hospice. Per LPA interview with HWD, facility does not have hospice care plan for R1. Per Title 22 regulation 87633(a)(4) Hospice Care of Terminally Ill Residents (a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met:(4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed ...prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s) (deficiency cited, see 809D). During initial annual inspection on 1/11/2024, LPA reviewed resident files at 3:30pm. LIC602 for R4 shows a DX of dementia; however, it has not been updated since 2021. Per Title 22 regulation 87705(c)(5) Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs (deficiency cited, see 809D). Additionally, the facility does not currently retain residents with DX of dementia. Per Title 22 regulation 87455(c)(3)(B) Acceptance and Retention Limitations (c) No resident shall be accepted or retained if any of the following apply: (3) The resident's primary need for care and supervision results from…: B) Dementia, unless the requirements of Section 87705, Care of Persons with Dementia, are met (deficiency cited, see 809D). Note: 809D final printed on 1/11/2024 amended to capture signature. Continued on 809C... Continued from 809... During initial annual inspection on 1/11/2024, at approximately 1:00pm, LPA observed medications to be centrally stored in a locked room in the assisted living building. Per LPA interview with Director of Health and Wellness (DHW) and Med Tech (S1) facility currently using an e-mar, maintaining Centrally Stored Medication Logs, and pre-pouring medications. LPA advised DHW per Title 22 regulation 87465(h)(5) Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers (deficiency cited, see 809D). LPA and S1 conducted spot check of medications. LPA and S1 reviewed medications for resident R2. LPA and S1 observed resident R2 to have 2 missed doses of Acetaminophen 325mg, Amlodipine 2.5 mg, and Furosemide 20 mg. Doses present in bubble packs, but documented as given to R2. LPA and S1 reviewed missed doses with DHW. LPA advised DHW per Title 22 regulation 87465(a)(4) Incidental Medical and Dental Care - The licensee shall assist residents with self-administered medications as needed (deficiency cited, see 809D). On 1/18/2024 at approximately 9:30am LPA reviewed staff files. Five [5] out of five [5] staff files either were missing the training log entirely, or the training log present did not show the number of training hours completed. Per Title 22 regulation 87412(c) Personnel Records (c) Licensees shall maintain in the personnel records verification of required staff training and orientation (2) Documentation of staff training shall include (D) Number of training hours per subject (deficiency cited, see 809D). Civil Penalty in the amount of $600 is being assessed for failure to correct deficiency 87405(a) cited on 1/11/2024 with plan of correction due date of 1/12/2024. CCL may assess $100 per day until deficiency is cleared and plan of correction is satisfied. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Evidence of Liability Insurance and Plan of Operation. Continued on 809C(2)... Continued from 809C... Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with ED. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with ED and a copy of this report was given.the state’s words, verbatim · CDSS document, Jan 18, 2024

The state marks this report as 9 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo conducted an unannounced Required - 1 Year annual inspection and met with Executive Director, Morgan Holien. There are currently 45 residents living in the Assisted Living (AL) portion of the facility and 113 residents living in the Independent Living (IL) portion of the community. There are no residents with a diagnosis of dementia and one resident receiving hospice care at the time of the visit. Required postings were observed. Facility contact information was reviewed. Fees are current at the time of visit. Beginning at 9:15 AM, LPA and ED toured assisted living portion of the community including activity rooms, grounds and kitchen (located in the assisted living). All interior parts of the facility were found to be a comfortable temperature. Exits and pathways were free from obstructions. Hot water temperature measured 117.7 F and 112.8 F, respectively, in faucets used by residents which is within regulation of 105 to 120 degrees F. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food quantity and quality stored in a safe manner for residents in care and staff as well as an emergency food supply. Meals are prepared in the main kitchen and brought to the dining room in the AL portion of the community for residents living there. LPA observed toxins in unlocked cabinet in ancillary Assisted Living Dining room. Per Title 22 regulation 87309 (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 (deficiency cited, see 809D). Fire extinguishers were current and charged as of December 4, 2023. Fire alarm system was tested and inspected; documentation of last inspection conducted on 10/17/2023 provided and documentation of sprinklers serviced on 6/19/2023 provided. A disaster drill was conducted on December 1, 2023.At approximately 12:30pm LPA and ED toured resident rooms and LPA interviewed residents. Continued on LIC809C... Continued from 809... Currently, facility does not have a qualified certified Administrator. Per Title 22 regulation 87405(a) Administrator - Qualifications and Duties(a)All facilities shall have a qualified and currently certified administrator (deficiency cited, see 809D). CCL has been corresponding with ED about issue of facility not having a qualified certified Administrator. Facility cited for deficiency of regulation 87405(a) on 11/03/2023. On 12/22/2023 LPA emailed ED to advise document submitted to CCL on 12/18/2023 does not specifically address how proposed Administrator will meet regulation 87405 Administrator Qualifications and Duties while working eight [8] in-person hours per week as identified in the submitted LIC500 Personnel Record. Also, CCL has not received requested Board Resolution Statement, designating an Administrator. Both aforementioned items were required to be submitted to CCL as agreed upon per CCL’s case management visit on 12/12/2023. Additionally, on 12/28/2023 CCL LPM emailed ED and requested that they resend the documents they previously sent to AdminCertInfo@dss.ca.gov as they were unable to find a record of ED’s certification (Cert. #6064643740). CCL did not receive a response from ED. On 1/10/2024 LPM emailed ED informing ED that CCL has not received a response to LPM’s request on 12/28/2023. Also, LPM advised ED that as of 1/10/2024 the ED is not on the Pending Administrator list. LPM requested ED provide an update regarding the aforementioned by the end of the day. No response received. LPA will return at a later to complete annual inspection. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Executive Director and a copy of the report was given.the state’s words, verbatim · CDSS document, Jan 11, 2024

The state marks this report as 14 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff mismanaged residents medication Staff did not seek medical attention in a timely manner

Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. Complainant alleges that staff made errors regarding resident's (R1) medications and that R1 was not provided timely medical attention following a fall on 10/31/2023. Through investigative interviews and review of pertinent documents, the following determinations are made: The specific medications and dates of alleged errors were not reported to CCL; Health Services Director states that any medications not given were due to R1's absence from the facility; Facility reports that R1 initially indicated a lack of pain and declined medical treatment following R1's fall; Staff reportedly checked R1 daily for changes in gait and pain; R1 was sent out for medical treatment on day three when R1 reported pain and requested treatment; Facility's Report of Injury (LIC624) conforms with staff statements regarding the accident. Although allegations may be true, based upon the statements made and documents reviewed, there is not a preponderance of evidence to prove the allegations are true or, not true. Therefore, the allegations are UNSUBSTANTIATED. Report left. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 19, 2023 · control 21-AS-20231113084830

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 19, 2023

Personnel Requirements. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. ***This requirement has not been met as evidenced by: Based upon review of call log records, out of 22 responses for calls to R1’s room in October, 2023, six exceeded 25 minutes and one was 126 minutes. This posed an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Dec 19, 2023

Plan of correction: Cleared at time of visit. Administration has submitted a written plan addressing timely responses to call buttons on 12/13/2023 for a more recent complaint regarding the same issue.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jan 2, 2024

Reporting Requirements…. A written report shall be submitted.. to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D…***Based upon statements made and documents reviewed, this requirement has not been met as evidenced by: R1’s Responsible Person states RP did not receive a copy of the Incident Report for 10/31 and the Report does not indicate a copy was provided to the Responsible Person. This posed a potential risk to the personal rights of R1.the state’s words, verbatim · CDSS document, Dec 19, 2023

Plan of correction: Administration will review the requirements of 87211 and provide refresher training to staff responsible for Incident Reports. Proof of refresher training will clear the deficiency when submited to CCL by the POC date.

Allegation investigated: Staff did not respond to a resident's call button in a timely manner

Licensing Program Analyst (LPA) Christi Coppo and Licensing Program Manager (LPM) Victoria Bertozzi arrived unannounced to conduct a complaint investigation. Staff did not respond to a resident's call button in a timely manner - Complaint alleges that resident fell and pushed thier call button for assistance but a caregiver did not respond in a timely manner. Per LPA review of call button log, there was at least one incident where there was a 94 minute delay following a resident fall. LPA and facility staff discussed areas of concern regarding the call button system and LPA will continue to work with facility to ensure resident safety. Based on record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Substantiatedthe state’s words, verbatim · CDSS document, Dec 12, 2023 · control 21-AS-20231206151404

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 13, 2023

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.... Licensee did not meet this requirement as evidenced by: Based on interview staff did not respond to a resident's call button in a timely manner.the state’s words, verbatim · CDSS document, Dec 12, 2023

Plan of correction: Facility agrees to submit written plan moving forward to ensure that resident call buttons are answered timely. Submission of written plan due by plan of correction (POC) due date of 12/13/2023.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christi Coppo and Licensing Program Manager (LPM) Victoria Bertozzi arrived unannounced to conduct a case management to follow up on facility's current lack of certified Administrator. Facility currently has 46 residents in care. At approximately 1:30pm LPA, LPM, and Executive Director, Morgan Holien discussed proposed Administrator, John Beltz and additional items that are still needed. Executive Director agrees to provide the following by December 18, 2023: Statement explaining how proposed Administrator will meet regulation 87405 Administrator Qualifications and Duties while working eight in person hours per week as identified in the LIC500 Personnel Record. Board Resolution designating Administrator LPA will follow up with Administrator Certification Unit regarding Executive Director's Administrator Certificate. No deficiencies cited.the state’s words, verbatim · CDSS document, Dec 12, 2023

Type of visit: Case Management - Incident

At approximately 8:40pm LPA Christi Coppo arrived unannounced to conduct a case management regarding Incident Report received on 10/24/2023. LPA met with Executive Director, Morgan Holien and requested resident's records to review. Per facility’s Incident Report: On 10/22/2023 at approximately 7:30am, the resident (R1) was returned to the facility by their son. The facility thinks that perhaps R1 left through their patio door. The patio door opens to the unsecured facility parking lot. The facility thinks that perhaps R1 walked over to a friend’s house and slept in their backyard. R1 woke up in the friend’s backyard on 10/23/2023 and then walked back to their son’s house. Facility thinks that R1 had experienced a fall at some point during their elopement because they had noticeable bruising on their head and a scraped area on their leg. Facility gave R1 a shower and dressed their scraped leg. Facility also put hourly resident checks in place when overnight caregiver or family is not present. At approximately 9:50am LPA met with Health and Wellness Director (HWD) Jody Livingston. HWD indicated that R1 moved into facility on 10/13/2023, not 09/30/2023 as reported on Incident Report indicated. Facility was advised by R1's son that R1 had a caregiver that will be with him 24 hours per day, one from 8:00am-8:00pm, and another from 8:00pm to 8:00am. Caregiver was placed by First Light Home Care (Director Maria Mann 707-501-9830). Per HWD, the family canceled the caregiver on 10/22/2023 but did not notify facility staff of cancelation. Per HWD, as a result of being informed that R1 had a caregiver, staff were not instructed to check on resident during the time frame of 8:00pm on 10/22/2023 to 7:30am on 10/23/2023. Therefore, no one at the facility realized the resident was gone until the resident's son brought the resident back to the facility at approximately 7:30am on 10/23/2023. At approximately 10:50am LPA reviewed R1’s LIC602 and observed the following: R1 has a diagnosis of Mild Cognitive Impairment with hypertension and coronary artery disease. R1 was not known to have wandering behavior or sundowning behavior, R1 is not able to leave the facility unassisted. Per HWD, on 10/24/2023 the resident's PCP came to facility to evaluate R1. Based upon evaluation, R1 had a medication added to address his Major Depressive Disorder. LPA reviewed e-Mar and confirmed addition of new medication. Per HWD, as of 10/24/2023, a private pay caregiver has resumed attending to R1 from 8:00pm-8:00am. Facility produced Hourly Status Check log indicating hourly staff check of R1, beginning 10/23/2023 at 9:00pm to address wandering behavior. At approximately 12:45pm LPA reviewed R1's updated Care Plan and confirmed that facility updated resident's Care Plan to monitor resident for wandering and/or elopement behavior. Per LPA interview with HWD, hourly monitoring of R1 will take place 4 times per AM and PM shift and 2 times per NOC shift. HWD agrees to update care plan with frequency of hourly checks. Continued on 809C.... continued from 809... LPA reviewed R1's intake Appraisal/Evaluation. R1's intake indicated he has a stage 3 or 4 pressure wound at time of admission. Intake completed by Health and Wellness Director (HWD) Jody Livingston on 9/29/2023. Per LPA interview HWD, the indication of a stage 3 or 4 pressure wound was a clerical error. LPA received signed statement from HWD indicating R1 was not admitted with a stage 3 or 4 pressure wound, nor does he have a stage 3 or 4 pressure wound currently. Per LPA's observation of DOJ database inquiry, current Executive Director Morgan Holien does not have fingerprint clearance as required per Title 22 regulation 87355(d). ED understands they must have fingerprint clearance in order to work at the facility. ED agrees to cease working at the facility until fingerprint clearance is obtained, not just applied for. ED is not associated to the facility either. ED agrees that they will pursue association to the facility before returning to facility. ED verifies that since 02/06/2023 she has been acting as Executive Director and pursuing Administrator certification and verifies that they corresponded about the process of submitting the application for Administrator certification with CCL LPA via email. Per ED, facility does not have a currently qualified and certified administrator. Facility to submit written plan indicating plan for implementation and start date of qualified and certified administrator. Plan to be submitted to CCL LPA by POC due date of 11/06/2023 Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Executive Director and a copy of this report was given.the state’s words, verbatim · CDSS document, Nov 3, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(d) · Plan of correction due date: Nov 6, 2023

Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted. Licensee did not meet this requirement as evidenced by; based on DOJ database report, Executive Director does not have fingerprint clearance.the state’s words, verbatim · CDSS document, Nov 3, 2023

Plan of correction: Executive Director to submit proof of correction indicating she will not be present or working at the facility, and will not return to the facility until after she has: obtained DOJ fingerprint clearance, is associated to facility, and submited proof of required clearance and association to CCL.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 6, 2023

Personnel Requirements – General(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Licensee did not meet this requirement as evidenced by; elopement of resident. This poses an immediate Health, Safety or Personal rights risk to residents.the state’s words, verbatim · CDSS document, Nov 3, 2023

Plan of correction: Facility agrees hourly checks of R1 will be increased to 4 times per AM and PM shift, and 2 times per NOC shift. Facility agrees to update care plan with frequency of hourly checks and submit to CCL LPA by POC due date of 11/06/2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(a) · Plan of correction due date: Nov 6, 2023

Administrator - Qualifications and Duties(a)All facilities shall have a qualified and currently certified administrator. Licensee did not meet this requirement as evidenced by; LPA interview with ED and record review, facility does not have a currently qualified and certified administrator. This poses an immediate Health, Safety or Personal rights risk to residents.the state’s words, verbatim · CDSS document, Nov 3, 2023

Plan of correction: Facility to submit written plan indicating plan for implementation and start date of qualified and certified administrator. Plan to be submitted to CCL LPA by POC due date of 11/06/2023