Oakmont of Carmichael

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday April 2, 2026 to complete the annual inspection. LPA and Lyndee toured the facility together to ensure the health and safety of residents in care. The areas toured included memory care and assisted living: resident apartments (12), resident bathrooms, common areas, kitchen, and courtyard. Facility had current inspection tags on fire extinguishers. Water temperatures were within the required range. Facility had fully stocked first aid kit. All required postings were observed. Facility was clean and well organized. In the areas toured, there were no health or safety violations observed. LPA obtained copies of updated LIC500, LIC610E, and current liability insurance. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Apr 2, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday April 1, 2026 to conduct the unannounced annual inspection. LPA Parks reviewed resident (9) and staff (6) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. Facility was in compliance for fire drills. Due to time constraints, the annual inspection will require a continuation. No deficiencies cited. Exit interview conducted. A copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Apr 1, 2026

Allegation investigated: Staff physically abused resident

Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday December 16, 2025, to conduct a complaint investigation regarding the above allegation. LPA met with Administrator Lyndee and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed management and staff regarding the incident. LPA learned the following: On 11/28/2025, S1 and S2 were assisting R1 with morning care. As R1 was getting out of bed, R1 slapped and scratched S2. S1 let go of R1’s arm. S2 was holding on to R1’s arm and bracing the back of their head so they wouldn’t fall backwards. Staff were then later able to assist R1 with incontinence care, dressing, and grooming. R1 has a diagnosis of dementia and a history of combative behavior. Unfounded Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegation is found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted. A copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 59-AS-20251208131000

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Melissa Parks arrived on Monday December 8, 2025 to conduct a case management visit regarding an incident that was reported to the Department on 12/2/2025. It was reported to the Administrator on 12/1/2025 regarding an incident that occurred on 11/28/2025. S1 and S2 were assisted R1 with morning care. As R1 was getting out of bed, R1 slapped and scratched S2. S1 let go of R1's arm. S2 was holding R1's arm and bracing the back of their head so they wouldn't fall backwards. Staff were then able to assist R1 with dressing and grooming. The facility reported the incident to R1's POA, Ombudsman, and Sheriffs Department. Facility is currently conducting staff training on the following topics: behavioral expressions, combative behaviors when performing ADLs, and mandated reporting. The facility will provide the LPA with training records when complete. Exit interview conducted. A copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 8, 2025

Allegation investigated: Staff disturbing resident’s sleep.

Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday November 5, 2025, to conclude a complaint investigation regarding the above allegation. LPA met with Natalie and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed management and care staff including AM, PM, and NOC shift. LPA learned the following: Allegation: Staff disturbing resident’s sleep. Staff interviews stated that they provide incontinent care for residents on a schedule, and as needed. NOC shift will provide care for residents throughout the night. As part of their assigned duties, staff provide routine incontinence care for residents. Additionally, there are four residents who staff are assigned to wake up and provide dressing/grooming assistance before their end of shift. Once the AM shift arrives, they provide dressing/grooming assistance for the remainder of the residents so that everyone is dressed Unfounded and ready when breakfast arrives. Although NOC shift staff do wake up residents to provide care and assistance with ADLs, LPA did not find that they were operating outside of the resident’s identified care needs. Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegation is found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted. A copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 5, 2025 · control 59-AS-20251020165401

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday November 5, 2025, to conduct a case management due to an incident report received by the Department on 11/2/2025. LPA met with Natalie, Resident Care Coordinator, and explained the purpose of the visit. LPA learned the following: there are currently 9 residents (3 in AL, 6 in MC) whose medications are not bubble packed. Each shift must do a narcotic count prior to leaving/starting their shift. On Sunday November 2, 2025, the AM Med Tech for memory care observed 5 pills in R1's non bubble packed narcotic bottle which were a different medication. Med Tech notified Health Services Director and Executive Director. R1 had not received this PRN narcotic since 8/3/2025. Additionally, LPA spoke with HSD and ED on the phone for additional information. Per ED, all med techs have been interviewed. All residents will be required to have all medication bubble packed moving forward. Facility sent out letters notifying families that this will be the resident/POA's financial responsibility beginning 2/1/2026. The facility will pay for the cost to bubble pack medications until 2/1/2026 for the 9 residents. LPA obtained a copy of R1's Drug Administration Record and PRN medication ability determination form. ED will send LPA a detailed summary of the investigation by end of day 11/7/2025. Additionally, HSD will provide additional training for all med techs. Health Services Director will provide LPA a copy of training when complete. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Executive Director.the state’s words, verbatim · CDSS document, Nov 5, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced and met with the Executive Director, Caroline Frangieh, to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed four (4) bedrooms in assisted living, two (2) bedrooms in memory care, two (2) hydro tub rooms, and seven (7) common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 116.9 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguishers and first aid kits are maintained and ready for emergency use. LPA reviewed three (3) assisted living resident files and two (2) memory care resident files. LPA also reviewed five (5) staff files. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, May 13, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Caroline Frangieh, to follow-up on an incident report received by the department on 3/12/25. On 3/12/25, Resident (R1) had an unwitnessed fall and was found on the floor of their apartment by care staff. R1 was sent to the hospital for further evaluation. Interview with Health Services Director indicated that R1 returned to the facility on 3/18/25 and is now receiving hospice care services. LPA obtained and requested documentation pertinent to the incident. Once all requested documentation is received, LPA will return to facility to complete the follow-up regarding the incident. During today's visit, no deficiencies are being cited. Exit interview conducted. A copy of report provided.the state’s words, verbatim · CDSS document, Mar 27, 2025

Allegation investigated: -Staff did not assist residents with care needs in a timely manner. -Staff did not ensure a comfortable environment was provided for residents. -Staff spoke to residents in an inappropriate manner. -Licensee did not ensure faucets for personal care delivered hot water. -Staff did not ensure facility cleanliness was maintained. -Staff were not adequately trained to care for residents with dementia. -Staff did not adequately assist resident with repositioning. -Staff did not provide quality food service to residents.

On 1/15/25, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Executive Director. LPAs conducted 3 inspections of the facility, facility and resident records were reviewed and interviews conducted of resident families, caregivers and managers. LPA is unable to find and or meet the preponderance, per policy. Evidence available did not reveal unmet needs of residents in memeory care in a timely manor. The department conducted a review of memory care residents' service plans and care records and found care provided for identified needs. Regulation requires room temperatures be maintained by heating rooms that residents occupy to a minimum of 68 degree F, (20 degrees C) and cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C). Inspections found that temperatures were maintained within required ranges when LPAs were present. Unsubstantiated The allegation that staff spoke to residents in an inappropriate manner lacked specific identification of individuals or time period. Interviews conducted failed to reveal evidence to support this allegation. Facility records and interviews found that a section of the building, far from the water heater, could at times take time reach the required temperature range of 105-120' F. Records showed that a repair was conducted to the water system within a reasonable time from when identified to when repaired. Inspections of the facility by LPAs found areas inspected to be clean and odor free. The allegation of a specific resident bathroom not cleaned between scheduled housekeeping was not able to be substantiated as there were not supported observations or statements. As a specific staff was not identified, a sample of staff training records were reviewed and found to meet regulation training requirements. While training requirements also include demonstrated competency, LPA referred to interview statements which did not reveal additional evidence. That staff did not adequately assist resident with repositioning was reported based on an overheard conversation. Without a specific resident or family member to interview, this allegation is unsubstantiated. Food supplies, menus and food safety were reviewed by inspection and found to meet requirements. Interviews found that resident food preferences are acknowledged and that residents with food intake issues are offered foods that which they are likely to eat and be assisted with intake as needed. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with administrator and report provided.the state’s words, verbatim · CDSS document, Jan 15, 2025 · control 59-AS-20240926163237

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 5/16/24 and met with the Executive Director, Luis Olivas, to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed four (4) bedrooms in assisted living, three (3) bedrooms in memory care, two (2) hydro tub rooms, and seven (7) common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 115 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguishers and first aid kits are maintained and ready for emergency use. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, May 16, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 5/10/24 and met with the Executive Director, Luis Olivas, to conduct a Required-1 Year Inspection. During today's visit, LPA reviewed three (3) assisted living resident files and two (2) memory care resident files. LPA also reviewed five (5) staff files. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. As a result of today's visit, no deficiencies were cited per California Code of Regulations, Title 22. LPA will return at a later time to complete annual inspection. Exit interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, May 10, 2024

Allegation investigated: -Staff are not providing adequate care and supervision to residents

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 1/11/24, and met with the Executive Director, Luis Olivas, to deliver complaint investigation findings into the allegation listed above. During a separate complaint investigation #59-AS-20230918125748 concluded on 12/1/23, it was discovered that care staff did not ensure that resident (R7) was receiving hourly checks as indicated in their care plan. It was also discovered that residents’ call button alerts were not responded to in a timely manner. Due to facility receiving a citation regarding the same violation in a separate complaint investigation conducted on 12/1/23, no additional citations will be issued regarding allegation. Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation was found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were cited during a separate complaint investigation conducted on 12/1/23 regarding the same violation. Exit interview conducted. Copy of report provided. Substantiated admitted to the care home on 9/10/23. Interviews with hospice nurses indicated that R1 began receiving hospice care services on 9/11/23. Interview with hospice nurse indicated that R1’s admission nurse arrived at the care home at 5pm on 9/11/23. Interview indicated that the admission nurse started R1’s medication list and ordered medications that were not present at the care home. According to interview, the orders were made after hours at 5pm on 9/11/23. Hospice nurse indicated that, because the order was made after hours, the medications should have arrived at the care home on 9/12/23 or 9/13/23. Hospice nurse indicated that there were no flags for late delivery of medication on R1’s chart. Interview indicated that R1’s first hospice case management visit was on 9/13/23 at 11am. Hospice nurse indicated that R1’s prescription for Seroquel was increased and made into a scheduled medication instead of a PRN. Interview indicated that an order for the Seroquel was placed at Rite Aid so that R1 could receive the medication right away. Any additional medications were ordered through the facility’s pharmacy. Interview with staff (S2) indicated that, when the hospice nurse arrived for R1’s first case management visit, they were trying to determine if R1’s medications had been ordered. S2 indicated that R1 still needed some of their medications filled. S2 stated the hospice nurse reordered medications for R1. S2 indicated that R1’s responsible party ordered the prescriptions through Rite Aid so R1 could receive the medications immediately. Interview with the Health Services Director indicated that R1’s responsible party was going to pick up any needed medications from the pharmacy and bring them to the facility later that day, 9/13/23. Interviews with S2 and staff (S3) indicated that R1 received their medications while at the care home. S2 indicated that medications waiting to be filled were not received. According to interviews, R1 moved out of the care home later in the day on 9/13/23. On 11/7/23, LPA conducted a medication count for residents (R4, R5, & R6) comparing medications to the facility’s Centrally Stored Medications forms. LPA did not observe any errors when comparing R4, R5, and R6’s medications that were counted to the Centrally Stored Medication forms. Interviews with residents (R2 & R3) indicated that they are receiving medications as prescribed. Allegation: Staff screamed at a resident while in care Interviews conducted with Memory Care Director, staff (S1), S2, and S3 indicated that they have never witnessed staff yell or scream at R1. S1 indicated that, if they witnessed staff scream at a resident, they ************************************************Continued on LIC9099-C********************************************** would let the Executive Director know. S2 and staff (S5) indicated that there was always another staff present in R1’s room, whether that be another care staff or hospice care staff. Interviews with S1, S3, staff (S4), and S5 indicated that they have never witnessed staff scream or yell at any residents in care. Interviews with R2 and R3 indicated that they have never witnessed staff mistreat residents in care. R2 and R3 indicated that they have never witnessed staff yell at residents in care. R2 indicated that staff treat them well. Based on medication count, interviews conducted, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations were found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted. A copy of this report was provided. for the two days that R1 was at the care home, as well as the $500 initial assessment fee. ED indicated that a refund check was printed by the facility on 9/22/23. ED indicated that the check was mailed via FedEx Priority Overnight mail to the responsible party on 9/28/23 and delivered on 9/29/23. ED stated that the care home originally had the wrong address for R1’s responsible party so they called to verify to ensure they had the correct address to send the check. ED provided LPA with the email correspondence with R1’s responsible party including the 30-day notice to vacate that was sent to the facility on 9/12/23. Also, ED provided LPA with email correspondence to R1’s responsible party sent from the ED on 9/21/23 indicating that the facility will be issuing a full refund, less the rent for the two days R1 was at the care home and $500 for the initial assessment. LPA received a copy of the check that was issued on 9/22/23, as well as a copy of the FedEx proof of delivery receipt showing the delivery was successful on 9/29/23. Based on interviews conducted and records reviewed, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 11, 2024 · control 59-AS-20230927093334

Allegation investigated: -Staff do not ensure records are properly maintained -Staff do not ensure care needs of resident are being properly met

Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 12/1/23, and met with the Executive Director, Kathleen Gilbey, to deliver complaint investigation findings into the above listed allegations. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. Allegations: Staff do not ensure records are properly maintained and staff do not ensure care needs of resident are being properly met. The relevant party indicated that staff were not documenting when hourly checks were being conducted for resident (R1). The log being used to document the hourly checks was being pre-filled by staff. Also, staff were not responding timely or at all when R1 would push their call button on their pendant. *********************************************Continued on LIC9099-C*************************************************** Substantiated Interview with the Executive Director (ED) indicated that the facility put in place a temporary plan of care for R1 requiring staff to conduct hourly checks due to the possibility that the call button pendants were not functioning properly in the memory care unit of the facility. Email correspondence between the ED and R1’s responsible party, dated 8/28/23, indicated that the facility will immediately begin conducting hourly checks on R1 until the facility is able to have a diagnostic check conducted on the emergency call button system. The ED indicated that a sign-in sheet was created to log the hourly checks and staff were instructed that it is necessary for them to record their hourly checks. Interviews conducted with staff (S1 & S2) indicated that care staff are to conduct hourly checks on R1 and fill out the log for the time the check was completed. Interviews also indicated that neither S1 nor S2 were aware of any care staff pre-filling the log before completing their hourly checks. Interview with S2 indicated that the hourly checks were a part of R1’s ADL/care plan until R1 moved out of the facility. According to R1’s care plan dated November 2023, R1 is to have status checks conducted 24 times per day. The facility provided the Department with the hourly check sign-in logs dated 8/28/23-9/18/23. There were several entries that were missing from the provided logs. Between 8/29/23 at 9:30pm to 8/30/23 at 2:30pm, there were no records of staff conducting hourly checks on R1. Between 9/1/23 at 5:30pm to 9/2/23 at 12:00pm, there were no records of hourly checks conducted. On 9/2/23, there were no entries between 6:12pm-10:40pm. On 9/3/23, there were no entries between 5:45am-7:05am, as well as 8:16am-10:20am. On 9/8/23, there were no entries between 12am-5am. On 9/11/23, there were no entries between 12pm-1pm. On 11/7/23, LPA conducted a visit at the care home and requested the facility provide documentation for the missing entries on the hourly check log. LPA was informed that the facility does not have any additional documentation to provide. According to the facility’s Emergency Response Systems Policies and Procedures dated October 2014, the care providers in the care home carry pagers. “When an alert is received on the pager the care provider will note if the alert is coming from one of their assigned residents and respond to the alert. If the care provider cannot promptly answer the alert because he/she is attending to another resident and cannot safely breakaway to answer the alert, the care provider will utilize their radio to request that another available care provider respond to the alert. The available care provider will acknowledge the request”. ************************************************Continued on LIC9099-C************************************************* Interview with the Vice President of Operations (VPO) indicated that there is no formal policy indicating an expected response time for staff to respond to a residents’ call button. VPO indicated that the facility’s expectation is for staff to respond immediately and that residents should not be waiting more than 15 minutes for a response from care staff. Interview with S2 indicated that staff are to respond to the call buttons right away. S2 indicated that, when care staff cannot respond to a call, they will reach out to another care staff member to respond. Interview with S1 indicated that the caregivers have pagers to inform them when a call button was pushed. Interview with R1 indicated that staff do not always come when they push their call button. R1 stated that staff have been better lately. R1 stated that maybe there are times when care staff are not available to respond to their call for assistance. According to the SMARTcare call button alert history dated between 9/13/23-9/18/23, there were 19 instances where care staff responded to residents’ calls for assistance between 26-42 minutes. There were an additional 16 instances where the alerts were never responded to. Between 9/13/23-9/18/23, there were 7 occasions that care staff responded to R1’s call button between 26 mins-35 mins and 11 occasions that the alerts were never responded to. Resident (R4) had 2 calls with a response time between 28-42 minutes and 3 alerts that were never responded to. Resident (R5) had 3 calls with a response time between 27-40 minutes. Resident (R6) had 3 calls with a response time between 34-41 minutes. Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Exit interview conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents. Interview with facility maintenance staff indicated that Phillips checked the call button system on 9/13/23 to ensure it was functioning in the memory care unit. Maintenance staff indicated that the pendants were checked and were all working properly. Maintenance staff completes a check of the pendants, egress, and wander guards for the facility monthly. According to the Lifeline report provided to the facility by Phillips on 9/13/23, Phillips conducted 3 checks in both memory care and assisted living and confirmed that all pagers were receiving calls in the facility. Interview with residents (R2 & R3) indicated that their call button pendants work properly. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 1, 2023 · control 59-AS-20230918125748

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Dec 15, 2023

87506 Resident Records (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the facility did not ensure R1’s records were maintained for hourly checks conducted, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 1, 2023

Plan of correction: Facility agrees to submit a statement of understanding as well as conduct a staff training to ensure staff understand the importance of documentation. Facility will also submit a list of all staff who attended the training by the POC due date of 12/15/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 15, 2023

87464 Basic Services (f) Basic services shall at a minimum include: (1) 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 evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure that R1 was receiving hourly checks or that residents’ call button alerts were responded to in a timely manner, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 1, 2023

Plan of correction: Facility agrees to submit a statement of understanding as well as conduct a staff training to ensure staff understand the caregiver expectations. Facility will also submit a list of all staff who attended the training by the POC due date of 12/15/23.