Oakmont of Brookside

Type of visit: Annual/Random

On 9-3-2026 at 9:45am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Tracy Burke and explained the purpose of the visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a residential care facility for the elderly (RCFE) with a current census of 70.Facility has a separate dining room and a formal living room space. The facility has an approved infection control plan in place. Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 73*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 1-26-26. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and accessible to staff. {Cont. on 809C} During this inspection 5 resident files and 5 staffing files were reviewed for regulatory compliance. All files contained required contents including staff training requirements. All staff reviewed contained criminal background clearances. LPA completed 4 resident interviews and 4 staff interviews. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility’s liability insurance is current and up to date per regulatory requirements. Facility does not contain any bodies of water. LPA observed personal rights and complaint information posted. Facility has appropriate internet access available for resident use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of residents in care. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills. LPA requested an updated copy of LIC 308 and LIC 500. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator.the state’s words, verbatim · CDSS document, Sep 3, 2026

Allegation investigated: Staff did not keep the facility clean and sanitary Staff is providing resident unauthorized medication Staff did not keep resident's authorized person informed regarding resident's care

On 4-24-2026 at 10:30am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegations noted above. LPA met with Executive Director Tracy Burke and explained the purpose of the visit. During this investigation, LPA conducted interviews with two staff members and one resident in care. Additionally, LPA reviewed facility file documentation including medication log sheets and physician orders, care notes, admissions agreement, individual service plan, and various email communications pertaining to this investigation. Additionally, LPA conducted a facility observation on 2-5-2026 Allegation: Staff did not keep the facility clean and sanitary. LPA conducted interviews and facility observations as noted above. Observations conducted included various resident rooms, common areas, and bathrooms within memory care and assisted living units. Based on these observations, facility was found to be clean and sanitary throughout including the bathroom areas. {Cont. on 9099C} Unsubstantiated Assigned staff were on duty and observed to be meeting the needs of residents in care. Interviews conducted did not reveal any corroborated statements of facility kept unclean or unsanitary. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. Allegation: Staff is providing resident unauthorized medication. LPA conducted interviews and record reviews as noted above. Based on review of care notes pertaining to resident1 (R1), it was revealed that medication Hydroxyzine HCL 25mg was given to R1 per physician’s orders which state: “Take 1 tab by mouth every 6 hours as needed for agitation.” Additionally, a review of facility care notes revealed communication between facility staff and responsible person for R1 regarding the use of the above medication which included a request by responsible person on 1-11-2026 to provide this medication due to R1 experiencing an agitated episode. Interviews conducted also confirm the above. As a result, there is not a preponderance of evidence to conclude staff has provided unauthorized medication to a resident. As a result, this allegation is UNSUBSTANTIATED. Allegation: Staff did not keep resident’s authorized person informed regarding resident’s care. LPA conducted interviews and record reviews as noted above. Based on review of care notes and email communications, it was revealed that various communications between staff and responsible party for R1 took place during January 2026 which included medication use and contents of R1’s care plan. Specifically, on 1-20-2026, care notes revealed that a care conference was conducted between facility staff and R1’s responsible persons which resulted in an adjustment to R1’s care plan and the addition of hands-on services. A review of email communication dated 1-21-2026 revealed a follow up email to R1’s responsible person to confirm the additional services to be added to R1’s care plan. The email also stated that no additional costs are to be imposed for this change at that time. Interviews conducted also confirm the above. As a result, there is not a preponderance of evidence to conclude that staff has not kept resident’s authorized person informed regarding resident’s care, therefore, this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director, and a copy of this report was provided. Appeal rights provided.the state’s words, verbatim · CDSS document, Apr 24, 2026 · control 27-AS-20260202215253

Allegation investigated: Staff is not allowing resident to receive visitations.

Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced facility visit in regards to a complaint investigation with the above allegation. LPA met with Administrator and explained the purpose of today's visit. During this investigation, LPA conducted interviews, inspected the facility and reviewed facility documents. Throughout the investigation, it was learned the facility documents visitors entering the facility. The facility received information regarding a questionable representation of a potential visitor and denied entry. The potential visitor was a former employee. Continued Unsubstantiated Records and interviews confirmed that the former employee resigned from the facility, and the resignation was accepted due to a potential conflict of interest. Facility leadership instructed the former employee not to conduct business with residents following their departure. Interview with R1 confirmed that they agreed with the facility’s determination regarding a potential conflict of interest and independently decided not to utilize services from the former employee. As a result of this investigation, the Department finds this allegation to be unsubstantiated.the state’s words, verbatim · CDSS document, Apr 13, 2026 · control 27-AS-20260108162141

Allegation investigated: Staff opened a resident's personal delivery

On 3/30/2026, LPA Johnson arrived unannounced to deliver finding for the above allegation. LPA met with Tracy Burke. Allegation: Staff opened a resident's personal delivery Based on interviews and information reported R1 stated that his Amazon Pharmacy medication delivery was sent to the facility’s med-tech room. R1 reported that staff opened the package without his knowledge or consent. Continued Substantiated R1 stated staff told him they “shook the package and it sounded like pills,” which led them to take possession of it. R1 reported that he did not authorize staff to open his personal packages. During the investigation, the facility did not provide documentation showing that R1 had delegated medication management team to open or granted permission for staff to open pharmacy deliveries on his behalf. Without such authorization, staff opening a resident’s personal package constitutes interference with the resident’s personal rights. Substantiated. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies were observed and cited during this visit. Exit interview held.the state’s words, verbatim · CDSS document, Mar 30, 2026 · control 27-AS-20251205104108

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 10, 2026

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by R1 not granted permission for staff to open pharmacy deliveries on his behalf. This is a personal right violation.the state’s words, verbatim · CDSS document, Mar 30, 2026

Plan of correction: The facility shall submit a plan on how this will not occur in the future along with a current in- service training on 87468.1 personal rights by POC due date. Please provided documentation to CCL by POC

Type of visit: POC

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an Annual Inspection on today's date of 8/19/2024. The LPA met with Nadya Rosales The following deficiencies, initially cited during a visit on 08/20/2025, have been cleared: Section Cited: 87465(d)(1) Date Due: 08/21/2025 Plan of Correction: Facility Administrator will review the section, 87465(d)(1). A statement of correction, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA’s email by the due date of 8/21/2025 COB at 5:00pm. Corrections: Cleared By Visit Clearance Date: 11/25/2025 Exit interview conducted.the state’s words, verbatim · CDSS document, Nov 25, 2025

Allegation investigated: Facility staff falsified resident's medical assessment Resident is being charged for services not provided

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to this facility to deliver complaint findings for the allegations above. Allegation: Facility staff falsified resident's medical assessment. Based on records reviewed and interviews conducted the facility provide R1's family with information that was part of the intake and assessment of a resident when they move-in or when information is not available to help determine the level of care. The facility staff did not give a diagnosis, but provides the family with a tool that helps the staff point the families into the right direction to meet the resident's needs. The staff denied giving a diagnosis of any kind. Continued Unfounded Allegation: Resident is being charged for services not provided. Based on records reviewed and observation the facility was establishing a plan of action for the R1 to be successful in orienting to the new environment. R1 did not have a primary care physician and therefore made the information on the physician's report to be generic and not reflective of the true needs of R1. The facility had to provide the family with updated information as that information was learned about R1. As such, the allegations listed are UNFOUNDED. The department has determined that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.the state’s words, verbatim · CDSS document, Sep 22, 2025 · control 27-AS-20250723130553

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an Annual Inspection on today's date of 8/19/2024. The LPA met with Tracy Burke. The facility is a two story structure located in North Stockton with a capacity to serve 81 resident and a current census of 77. The grounds were observed to be maintained and clear of obstruction and debris. There is sufficient outdoor furniture for the residents to participate in outdoor activities and pergolas for shade. LPA and Staff inspected the physical plant at to ensure the health and safety of the clients in care. LPA inspected the facility with Staff including but not limited to the kitchen area, resident rooms, bathrooms, dining room, and storage areas. The facility had the required carbon monoxide detectors. LPA observed the facility to be free of odor. LPA observed sufficient lighting throughout the facility. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Fire drill was conducted on 8/2025. Continued LPA reviewed twenty (15) client files and five (5) staff files, including criminal record clearances. LPA observed centrally stored medications locked in then medication room. LPA reviewed and compared resident medication vs. resident medication logs. As well as the over the counter medication prescribed by residents primary care physicians. All staff were cleared and associated to the facility. First aid kit was checked and is complete. During the file review for residents in care LPA and Administrator observed outdated (2023) PRN letters for 5 of 10 memory care files reviewed. LPA, Administrator and Med-tech reviewed PRN letters and learned that the facility is not following the request of the doctor to be notified before and after medications are given. Citation given Advisory given for reporting requirements. Exit interview conducted. A copy of this report was left with the Administrator.the state’s words, verbatim · CDSS document, Aug 20, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(d)(1) · Plan of correction due date: Aug 21, 2025

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met:(1)Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. This requirement was not met as evidenced by records reviewed and interviews with staff. The facility is not following the Doctor's orders as requested in the current and outdated PRN letters for R1 through R7the state’s words, verbatim · CDSS document, Aug 20, 2025

Plan of correction: Facility Administrator will review the section, 87465(d)(1). A statement of correction, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA’s email by the due date of 8/21/2025 COB at 5:00pm. Information submitted must include. Attendees, trainers, and information discussed.

Allegation investigated: Facility is in disrepair. Licensee does not ensure that residents are provided a comfortable environment while in care.

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to deliver findings for complaint investigation for the allegations noted above. LPA met with Administrator and explained the purpose of the visit. Allegation: Facility is in disrepair. Based on records reviewed and interviews with the Administrator and staff. The facility had a broken alarm system (wander management system) This was reported to the facility Administrator on 9/24/2024. The alarm system was triggering more frequently than usual from 9/24/2024 through 10/23/2024. The facility did not have a Maintenance Director at the time of the incidents and the staff or Administrator would have to call Phillips lifeline systems to have the system reset. Substantiated The facility does not have records of correspondence with Phillips regarding the frequency of the incidents are the calls to them to reset the system. However, the facility has requested time to get this information by next week 4/25/2025. The facility continued to have issues with the system triggering each time the alarm was triggered the staff would have to put a code in to stop the system. This continued until 10/23/2024 when the system was repaired. Although the facility is not in disrepair the facility did have a broken system that when triggered provide resident in care with and without hearing impairments a very uncomfortable environment. Allegation: Licensee does not ensure that residents are provided a comfortable environment while in care. Based on the review of records the facility provides care to residents with cognitive impairment as well as hearing impairment. The use of auditory alarms that alert staff to residents attempting to leave is what the facility chooses to use, however, based on the repair and auditory frequency of the alarm going off the residents in care with or without hearing impairments were subjected to the noise and as a result were exposed to a uncomfortable environment. The department concluded the initial investigation and the preponderance of evidence standard was met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted.the state’s words, verbatim · CDSS document, Apr 18, 2025 · control 27-AS-20250128134248

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 25, 2025

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 records reviewed The alarm system was triggering more frequently than usual from 9/24/2024 through 10/232024. The facility did not have a Maintenance Director at the time of the incidents and the staff or Administrator would have to call Phillips lifeline systems to have the system reset after putting a code in to stop the alarm.the state’s words, verbatim · CDSS document, Apr 18, 2025

Plan of correction: The facility repaired the system of 10/23/2024. The facility provided an invoice #1307 dated 1/30/2025 and currently uses a remote to stop the alarm when triggered. The facility submitted a letter to the Division of Occupational Safety and Health dated 3/26/2025 regarding complaint # 2274922 with inaccurate information about the Department's findings and will need to report the current findings to Mr. Valadez of the Dept. of Industrial Relations(DIR)/ Division of Occupational Safety and Health by 4/21/2025. The Department will also cross report the current and accurate findings to DIR.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Apr 25, 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 as evidenced by based on the repair and auditory frequency of the alarm going off the residents in care with or without hearing impairments were subjected to the loud noise and as a result were exposed to a uncomfortable environment.the state’s words, verbatim · CDSS document, Apr 18, 2025

Plan of correction: The facility repaired the system of 10/23/2024. The facility provided an invoice #1307 dated 1/30/2025 and currently uses a remote to stop the alarm when triggered.

Type of visit: Case Management - Incident

LPA Johnson arrived unannounced to follow-up on an incident report for a resident with an infected wound. The facility has a Resident (R1) with a health condition that required hospitalization to receive treatment if the condition becomes unstable. The resident moved into the facility recently and has been utilizing the wound clinic to treat the condition. The facility recently sent R1 out as a result of cellulitis to bilateral lower extremities. The facility will reassess prior to R1 returning to the facility after R1 completes treatment for the underlying condition. LPA will return at a later date to follow-up on the discharge plan and reassessment for R1. Exit interview conducted.the state’s words, verbatim · CDSS document, Apr 4, 2025

Type of visit: Case Management - Incident

LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during case management visits, annuals and complaint investigations. Deficiencies cited under Title 22 Regulations have been cleared. Licensee complied with the terms of all POCs LPA was unable to clear two citations under appeal from 3/14/2024. Exit interview conducted.the state’s words, verbatim · CDSS document, Dec 13, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an Annual Inspection on today's date of 8/19/2024. The LPA met with Tracy Burke. The facility is a two story structure located in North Stockton with a capacity to serve 81 resident and a current census of 72. The grounds were observed to be maintained and clear of obstruction and debris. There is sufficient outdoor furniture for the residents to participate in outdoor activities and pergolas for shade. LPA and Staff inspected the physical plant at to ensure the health and safety of the clients in care. LPA inspected the facility with Staff including but not limited to the kitchen area, resident rooms, bathrooms, dining room, and storage areas. The facility had the required carbon monoxide detectors. LPA observed the facility to be free of odor. LPA observed sufficient lighting throughout the facility. Fire extinguishers and smoke detectors are current and in compliance with fire safety. However, during the tour of the kitchen, LPA and Dietary Supervisor observed out dated Ansul/Fixed system. The system was due for semi-annual service on 3/2024. Fire drill was conducted on 7/17/2024. Continued LPA reviewed twenty (20) client files and five (5) staff files, including criminal record clearances. LPA observed centrally stored medications locked in then medication room. LPA reviewed and compared resident medication vs. resident medication logs. As well as the over the counter medication prescribed by residents primary care physicians. All staff were cleared and associated to the facility. First aid kit was checked and is complete. Citations given for fire clearance violations with civil penalties assessed.(Photos taken) Advisories given for South elevator being out of service, and food handlers card for the Sous-Chef (Start date for employment was July 2024). The two gas generators inspected, both inspected gas generators were very low on gas (less then a quarter of a tank). (Photos taken) Exit interview conducted. A copy of this report was left with the Administrator.the state’s words, verbatim · CDSS document, Aug 19, 2024

Type of visit: Case Management - Other

On 7/5/2024, LPA Johnson arrived unannounced to follow-up on a request for an exception for a prohibited Health Condition. The facility has retained a Resident (R1) with a prohibited health condition unstageable pressure injury to the right heel. Home Health agency has been working with R1 from 5/6/2024 to present the facility has third party notes for home health service that have been in place to address a pressure injury to the lower back or tailbone area, right heel and arms. The facility does have orders from the doctor for the 5/6/2024 initial home health services and has recently received notification from the home health RN on 7/2/2024 that R1 has an unstageable pressure injury to the heel and service will be discontinued. R1 was sent out by the facility to have the injury on the right heel assessed on 6/30/2024. R1 was returned to the facility with no orders to continue home health services for nursing. The injury on the right heel is unstageable and treatment is not viable. Continued On 7/3/20204, The facility requested skilled nursing from R1's primary physician. Also noted during the inspection of documents was information about R1's development of a blood blister on the right heel (large hard eschar approximately 1 to 2 inches) about a month ago according to the discharge papers dated 6/30/2024, R1 was prescribed some medication but R1's daughter cannot recall what kind of medication it was. The facility has no record of medication for R1 for treatment of the blood blister. R1 is a self medication administer. The facility did not have the self-medication evaluation form for R1. The preplacement appraisal dated 4/30 2024, does not include information about treatment plans for the pressure injuries noted on the plan of care from home health dated 5/6/2024. The facility has requested a exception for R1 dated 7/3/2024.the state’s words, verbatim · CDSS document, Jul 5, 2024

Type of visit: Case Management - Incident

On 5/10/2024 Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced case management visit to the facility for incidents of unwitnessed and witnessed falls. R1 had a witnessed fall on 5/1/2024, R1 was taken to the ER and was diagnosed with a fracture of the Tibial Plateau. R1 returned to the facility on hospice. R1 service plan dated 4/16/2024 confirmed that R1 was a two person assist with transferring. Based on the incident report dated 5/7/2024, R1 was transferring from the recliner chair to the wheelchair and fell. R1 was being assisted with transferring by S1, the facility did not have as assessed a second person to assist with the transfer and as a result R1 fell and sustained a fracture. R2 was sent out on 4/13/2024 for evaluation from feeling sleepy and lethargic. During the review of the file the department discovered that R2 had a fall on 4/15/2024 witnessed by R2's wife and reported to the facility. R2 was sent out to the ER at St. Joseph's hospital. The discharge summary listed the chief complaint as a fall yesterday(4/15/2024) w/subdural hemorrhage. R2 was discharged and scheduled to see the primary care physician on 5/8/2024. R2 did not return to the facility after April 15th 2024. Continued R3 had an unwitnessed fall and was sent out to San Joaquin General ER. R3 was diagnosed with a Hematoma to the forehead. R3 was to follow-up with primary care physician. During the review of the file the department observed an outdated Physician's report. (LIC 602 4/27/2024). Deficiencies are cited on 809-D, per Title 22 Regulations, Division 6. At the time of the complaint visit, an immediate civil penalty of $500 shall be assessed for a violation of California Code of Regulations Section 87464(f)(1). The licensee was informed that an enhanced civil penalty (ECP) was pending review and may be assessed according to Health and Safety Code 1569.49(f). Once civil penalty assessments have been determined, an LPA will return at a future date to assess the civil penalties. Exit interview was conducted. Appeal rights given.the state’s words, verbatim · CDSS document, May 13, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: May 15, 2024

87464 (f)(1) Basic services care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Based on the department's findings, the facility did not provide adequate care and supervision including a two person assist which resulted in R1 sustaining a fracture from a fall while transferring. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, May 13, 2024

Plan of correction: Licensee agrees to submit a plan of correction to LPA by 5/15/2024 on how the facility will be in compliance with regulation 87464(f)(1) at all times. Civil penalty assessed

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(c)(5) · Plan of correction due date: May 17, 2024

87705(c)(5)Care of Persons with Dementia Licensees who accept and retain residents with dementia shall ensure that each resident with dementia has an annual medical assessment and a reappraisal done at least annually This requirement was not met based on records reviewed, The department observed R3 with an outdated LIC 602/ Physician report expired. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 13, 2024

Plan of correction: All residents diagnosed with dementia will be scheduled with their responsible physician and be assessed for any changes to their needs with an updated LIC 602. Statement of correction, with copy of updated LIC 602, to be completed and submitted into CCL by the due date

Type of visit: Case Management - Incident

Report was amended to change the plan of correction date from 5/11/2024 to 5/15/24. The updated report is dated 5/13/2024.the state’s words, verbatim · CDSS document, May 10, 2024

Type of visit: Case Management - Incident

On 4/4/2024, Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced Case Management visit today at the facility. The department received two incident reports dated 3/28/2024 for a medication error for (R1) and 4/2/2024 for an unwitnessed fall for (R2). LPA toured the facility and interviewed the Administrator about the events related to the medication error and the resident's fall. The LPA reviewed resident records, staff records and staff training records. Medications and medication procedures were also reviewed. Both incident have been investigated by the department. The department confirmed that the facility has addressed these issues with an in-service training for Med-techs and has been actively working on the service plan for R2 since 9/29/2023. R2 was taken by the family to urgent care for a rash on 3/24/2024. R2 was diagnosed with Shingles and given two medications on that date. Both incidents were self reported by the facility. Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were cited during this visit. Advisories were given. Exit interview held and appeal rights given.the state’s words, verbatim · CDSS document, Apr 4, 2024

Allegation investigated: Staff did not seek timely medical care for resident Staff do not have the required training Staff did not give resident medication.

On 3/14/2024, LPA Johnson arrived unannounce to deliver finding for the above allegations. LPA met with Nadya Rosales. Allegation: Staff did not seek timely medical care for resident. The allegation is substantiated based on records reviewed and interview with staff. The department discovered through progress notes dated 12/3/2023 that the facility's staff observed R1 on the floor by the bed. R1's family and physician were notified. On 12/6 2023, facility staff called Power of Attorney/ family and informed them that the Primary Care Physician (PCP) wanted to see R1 in the PCP's office. Staff was told by POA/Family, "that's not going to happen. I (POA) will call the doctor to come out and see her." The Doctor never came out to see her and R1 did not go to the doctor office. Continued Substantiated On 12/16/2023, R1 had a witnessed fall at approximately 3:00pm. At 3:45pm, the facility called POA and left a message. The facility's alert charting dated 12/16/23, 8:49pm stated that the POA was contacted and did not want R1 to be transported by ambulance. POA wanted to be updated should anything change. At 11:04pm the facility alert notes confirmed that R1 was sent out to the ER were R1 was admitted at 9:43am and the diagnoses was a rib fracture. Civil penalty assessed. Allegation: Staff do not have the required training. Based on records reviewed and interviews with staff the facility did not reorder medication prior to R1 running out of medication causing R1 to without two medications for seven days from 9/14/2023 until 9/21/2023. The facility attempted to get the medications for R1 via faxing request to the Primary Care Physician. However the information was not confirmed to be ordered by the PCP until the 9/21/2023. This is a training issues and supports the substantiated allegation. Allegation: Staff did not give resident medication. Based on records reviewed and interviews with the staff the facility was out of 2 medications for R3 from 9/14/23 to 9/21/23. Substantiated. Allegation: Residents are not being cleaned properly after changing depends. Based on interviews with staff and residents along with attempted interviews with residents in memory care the facility is providing care and support. The residents confirmed that they are provided with assistance during mealtimes, activities time and personal care. LPA was unable to confirm that the residents in memory care interviewed understood the questions and were not good witnesses. The allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Mar 14, 2024 · control 27-AS-20240109094301

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(6) · Plan of correction due date: Mar 22, 2024

87464 Basic Services (f) Basic services shall at a minimum include: (6) Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by The facility not following the doctors orders and not taking R1 to be checked after the fall on 12/3/23 at the request of the PCP. R1 had another fall at approximately 3 pm and was told by POA not to transport R1 via ambulance. Later in the evening R1 requested to go to the ER and was diagnosed with fractured ribs.the state’s words, verbatim · CDSS document, Mar 14, 2024

Plan of correction: Licensee to ensure all staff are up to date and are knowledgeable of the latest PINs and regulations. LPA to receive confirmation of review of the last PIN with staff by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 22, 2024

Incidental Medical and Dental Care. (a) plan for incidental medical and dental care shall be developed by each facility (1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on record reviews and interviews, licensee did not ensure physician was efficiently notified for medication order clarification for R1. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 14, 2024

Plan of correction: Licensee will submit a plan which ensures physician’s are efficiently and effectively notified for any resident care needs. Plan to be submitted to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 22, 2024

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking This requirement was not met as evidenced by R1 being without medication for seven days. This is a potential health and safety risk to resident in carethe state’s words, verbatim · CDSS document, Mar 14, 2024

Plan of correction: The facility shall conduct a staff in-service training with all staff who distribute medication on proper medication storing and ordering, distribution, training shall include but is not limited to applicable laws in regards to medications. Proof of training shall be sent to Licensing by 03/22/2024

Type of visit: Case Management - Other

LPA Albert Johnson made an unannounced visit to the facility to open a complaint and to verify that the facility has an administrator to replace the current administrator who's last day of work as the administrator was 1/12/2024. The facility has identified an interim Administrator(No documents sent to the department . The facility has not provided the required documentation to the department to assist with the transfer of administrator's responsibilities and will be given a citation today. Based on records reviewed and interviews with S1 on 1/16/2024 the facility does not have an Administrator of record. S1 is working here on an interim bases until the permanent administrator's including documents/information is forwarded to the department. The department was unable to confirm through Licensing Information System that interim Administrator is associated to this facility as of 1/16/2024. Exit interview conducted, a copy of this report and appeal rights given.the state’s words, verbatim · CDSS document, Jan 16, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a-d) · Plan of correction due date: Jan 17, 2024

87405(a-d) All Facilities shall have a qualified and currently certified administrator.... This requirement was not met as evidenced by records reviewed and interviews with staff. This is an immediate risk to operations and care of residents.the state’s words, verbatim · CDSS document, Jan 16, 2024

Plan of correction: Licensee will submit to LPA an updated LIC500, LIC200 and other documents required 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 1/17/2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(2) · Plan of correction due date: Jan 17, 2024

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or... Based on observation, the Licensee did not ensure all staff were associated to the facility. The LPA observed that S1 was not associated to the facility. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 16, 2024

Plan of correction: The Licensee will request a criminal record transfer for S1. The Licensee will review the staff roster and ensure all working staff are associated to the facility. Proof of S1 being associated to the facility due by the POC due date of 1/17/2024.

Allegation investigated: Facility staff did not ensure resident's hygiene needs are being met Resident was left in dirty clothing Resident was served contaminated food Facility staff do not provide adequate activities for residents

Allegation: Facility staff did not ensure resident's hygiene needs are being met. Based on records reviewed and interviews with the staff the facility documents when a resident has been given hygiene care. LPA was able to confirm that the documentation the facility uses includes: changing clothing, showers, incontinent care, assistance and escorting with reminders for mealtimes. During the course of the investigation the department was unable to confirm that a particular resident's hygiene needs were not met. Allegation: Resident was left in dirty clothing. Based on records reviewed and interviews conducted the facility documents when residents are assisted with choosing clothing , dressing and undressing with reminders to maintain privacy, safety, comfort and to report any decline in abilities to assist with this activity. Allegation: Resident was served contaminated food. Based on records reviewed and interviews conducted the facility is in compliance with regulatory requirements for food service and preparation. The allegation mention that a fly was in the food of a resident when served. The facility had no record of the event (over the last three months) and those interviewed confirmed that this did not happen or was not reported by the resident council, staff or family members. LPA did not have evidence (photos or documentation) to support the allegation. Allegation: Facility staff do not provide adequate activities for residents. Based on observation and records reviewed the facility has a current activities calendar, a staff assigned to carry out the activities and photos of residents engaging in activities. The resident council confirmed that there are improvements that can be made however they are satisfied with the variety of activities offered. Resident council also noted that the facility should given more notice when activities are cancelled. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 14, 2023 · control 27-AS-20230927085042

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility staff mismanage medications.

This matter was addressed and substantiated on the complaint report with the control number 7-AS-20230807125824 dated 8/28/2023. The facility was given a citation for mismanaging medication for R1 from 1/4/2022 thru 1/13/2022 and 2/6/22 thru 2/8/22. There were two medication not available for R1 on two different occasions. The facility's medication records confirmed that the medications were ordered but not available on-site. The department concluded the initial investigation and the preponderance of evidence standard was met, therefore the above allegation is found to be SUBSTANTIATED. A citation was given on 8/28/2023 with a plan of correction, therefore the department will not be re- issuing a citation. Substantiatedthe state’s words, verbatim · CDSS document, Oct 30, 2023 · control 27-AS-20230925125951