Oakmont of El Dorado Hills

Type of visit: Case Management - Other

Licensing Program Analysts, (LPAs) Lavinia Muscan and Talwinder Bains arrived on August 12, 2026, for an unannounced inspection, to follow up on substantiated allegations of neglect that resulted from a complaint investigation. On April 8, 2025, the Department concluded a complaint investigation regarding the following allegations: Staff did not provide adequate supervision, resulting in a resident sustaining a fracture while in care, and Staff did not prevent resident from suffering multiple falls while in care. The licensee was cited for California Code of Regulations (CCR) Title 22, §87463-Reappraisals, and (CCR) Title 22 §87468.2- Additional Personal Rights of Residents in Privately Operated Facilities. At the time of the complaint visit on April 8, 2025, an immediate civil penalty of $500 was issued. The licensee was informed that an additional civil penalty was under review and may be assessed at a future date according to Health and Safety Code §1569.49(f). Continued on page 2 ... Page 2 ... The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code §15610.67 defines serious bodily injury as, “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not providing adequate supervision resulting in a resident (R1) sustaining a broken collar bone that required hospitalization and stitches. Today, August 12, 2026, the Department will be issuing a civil penalty per Health and Safety Code §1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on April 8, 2025, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Brian Bankson signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Aug 12, 2026

Allegation investigated: Staff do not wear hairnets while handling food for residents. Staff serving residents cross-contaminated food.

On 7/16/2026, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to do complaint investigation into the allegations listed above and met with Administrator Brian Bankson. Based on facility tour, record review, staff and residents interviews, that dietary staff have their food handlers certificate and staff know how to handle and serve food. Staff interviews indicated that they were aware of infection control guidelines and there were no issues in this area. Residents interviews did not reflect any concerns with facility's food service. Facility tour indicated that staff were following infection control guidelines for food handling per Department guidelines without any concerns. Based on this information, the above allegations are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview was conducted and a copy of the report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Jul 16, 2026 · control 59-AS-20260713101403

Allegation investigated: Staff are mismanaging residents medication

On 7/13/2026, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Brian Bankson. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:Based on resident interviews, staff interviews, and a review of facility records, there was insufficient evidence to support the allegation. Documentation reviewed, including medication administration records, indicated that staff followed the physician’s orders and the facility’s medication administration procedures. Interviews with staff and the resident were consistent with the documentation reviewed. Therefore, the allegation that staff did not administer the resident’s medication as prescribed is 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 conducted. Report left with facility. Unsubstantiated Staff are not providing adequate food service for residents The Department conducted interviews and reviewed facility records, including menus, food service logs, and related documentation. The investigation did not reveal any evidence to support that staff failed to provide adequate food services. Information obtained during the investigation indicated that meals were provided in accordance with established menus and dietary requirements, and that food service operations were conducted consistent with facility procedures. There were no observations, documentation, or credible statements to substantiate the allegation. Therefore, the allegation is determined to be UNFOUNDED. Staff are not providing a comfortable environment for residents Based on resident interviews, there is insufficient evidence to support the allegation. Residents consistently reported that staff are welcoming, helpful, and kind. Residents also stated they are happy living at the facility and feel comfortable in the environment. No evidence was obtained to indicate that staff failed to provide a comfortable living environment for residents. Therefore, the allegation is determined to be unfounded. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff are not keeping residents documents updated Based on documents obtained and statements reviewed, the department determined the Licensee ensured that a complete and current record, including Admission Agreement, Needs and Service plan, Physician’s report etc. was maintained for residents in care. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff did not respond to the residents pendant call in a timely manner The Department conducted interviews and reviewed facility records, including incident reports, care logs, and related documentation. The allegation did not reveal any evidence to support staff failed to respond timely to residents’ alerts. Information obtained during the investigation indicated that staff responded appropriately and within required time frames when alerted by residents. There were no observations, documentation, or credible statements to substantiate the allegation. Therefore, the allegation is determined to be UNFOUNDED. Facility is not kept free of pests Based on documents obtained and statements reviewed, the department determined that there was insufficient evidence that the facility is not kept free of pests. The facility representative stated that the pest control company comes in monthly, and more often as needed. Four (4) staff and three (3) residents were interviewed and stated they have not seen any pests at the facility. During 05/19/2026 and 06/23/2026 visits, the facility was toured and documentation from the pest control company was provided. Therefore, the above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Jul 13, 2026 · control 59-AS-20260513120408

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lavinia Muscan arrived on 6/23/2026 to conduct the annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed five resident (5) and five staff files (5). All resident files contained the required paperwork. All staff files contained the required paperwork. Facility was clean and well organized. Facility is current on fire drills. All required posting were observed. Staff training contained the required initial training. LPA and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, dining room, hallways, and common areas. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. The disaster drill is current. The administrator's certificate is current. LPA checked the kitchen area for the ability to prepare and store food. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector are operational. Fire extinguisher is ready for emergency use. Water temperature is within compliance. In the areas toured, there were no health or safety violations observed. LPAs requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by end of the month. Exit interview conducted. A copy of this report was printed and given to facility.the state’s words, verbatim · CDSS document, Jun 23, 2026

Allegation investigated: Staff did not ensure prescribed medications were properly dispensed. Staff did not properly document residents’ medication log. Staff do not ensure that medications are not accessible to residents in care. Staff left resident soiled for an extended period of time resulting in resident obtaining a UTI.

On 04/27/2026, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Chad Rogers. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unsubstantiated Staff did not ensure prescribed medications were properly dispensed. Staff did not properly document residents’ medication log. Staff do not ensure that medications are not accessible to residents in care. The Department conducted interviews and reviewed facility records, including MARs and supporting documentation. The investigation did not reveal sufficient evidence to support that prescribed medications were not properly dispensed in accordance with physician orders and facility procedures. Information obtained indicated medications were administered as prescribed. Interviews and a review of the MARs and related medication documentation did not provide sufficient evidence that medication logs were not properly completed or maintained. Records reviewed did not demonstrate systemic or substantiated deficiencies in medication documentation practices. The Department reviewed facility medication storage practices and conducted staff interviews. The investigation did not provide sufficient evidence to support medications were accessible to residents in violation of requirements. Information obtained indicated medications were stored in a manner intended to prevent unauthorized access. Although allegations were made, the preponderance of evidence standard was not met for any of the allegations. Therefore, the allegations are determined to be UNSUBSTANTIATED. Staff left resident soiled for an extended period of time resulting in resident obtaining a UTI. The Department conducted interviews and reviewed facility records, including care notes, incident documentation, and medical information available at the time of the investigation. The investigation did not provide sufficient evidence to support that staff left a resident soiled for an extended period of time. Additionally, there was no evidence obtained during the investigation establishing a causal relationship between facility care practices and the resident’s diagnosis of a urinary tract infection. Information reviewed indicated resident care was provided in accordance with established care plans and facility procedures. Although the allegation was made, the preponderance of evidence standard was not met. Therefore, the allegation is determined to be UNSUBSTANTIATED. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Apr 27, 2026 · control 59-AS-20260209155910

Allegation investigated: Staff mishandle the residents medications

On 04/27/2026, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Chad Rogers. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.The results of the investigation are as follows: The Department conducted interviews and reviewed facility records, including MARs, medication logs, and related documentation. The investigation did not provide sufficient evidence to support that staff mishandled resident’s medications. Records reviewed and information obtained indicated medications were stored, dispensed, and documented in accordance with facility procedures and physician orders. Although the allegation was made, the preponderance of evidence standard was not met. Therefore, the allegation is determined to be UNSUBSTANTIATED. Exit interview conducted. Report left with facility. Unsubstantiated Staff do not timely respond to the residents alerts The Department conducted interviews and reviewed facility records, including incident reports, care logs, and related documentation. The allegation did not reveal any evidence to support staff failed to respond timely to residents’ alerts. Information obtained during the investigation indicated that staff responded appropriately and within required time frames when alerted by residents. There were no observations, documentation, or credible statements to substantiate the allegation. Therefore, the allegation is determined to be UNFOUNDED. Staff do not provide adequate food service The Department conducted interviews and reviewed facility records, including menus, food service logs, and related documentation. The investigation did not reveal any evidence to support that staff failed to provide adequate food services. Information obtained during the investigation indicated that meals were provided in accordance with established menus and dietary requirements, and that food service operations were conducted consistent with facility procedures. There were no observations, documentation, or credible statements to substantiate the allegation. Therefore, the allegation is determined to be UNFOUNDED. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Apr 27, 2026 · control 59-AS-20260311142529

Allegation investigated: Staff not providing medical attention to resident in a timely manner. Staff are not following resident’s care plan.

On March 3, 2026, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Chad Rogers. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unfounded Staff not providing medical attention to resident in a timely manner. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. Based on five (5) staff and three (3) resident interviews, the typical response time for staff responding to a resident’s call alert ranges from 5 minutes to as soon as possible. Residents interviewed stated they have not had issues with staff not responding timely. Staff interviews indicated that staff usually respond to residents’ call buttons within 5 minutes or sooner. Staff stated they know the protocol on how to address any medical intervention, and residents had no concerns with timely medical attention. Additionally, staff stated that EMS is right around the corner and arrives quickly if needed. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff are not following resident’s care plan. The department conducted interviews regarding this allegation. Record reviews and interviews with staff indicated that staff were aware of residents’ care and service needs based on residents’ needs and service plan. Department review of residents’ documentation; Physicians Report, Service and care plan, and interviews conducted revealed that staff were following resident’s needs and service plan as documented. After review of residents’ files and medical records, department also concluded that facility was following up with residents’ doctor, family and department as needed; therefore, above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Mar 3, 2026 · control 59-AS-20251205090838

Allegation investigated: Staff mishandle the residents medications

On 11/24/2025, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Chad Rogers. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Based on documents obtained and statements reviewed for October 2025, the department determined that there was insufficient evidence that any medication errors have occurred. Documents obtained show that all current medications were administered and logged correctly for residents per their doctor’s orders. Eight staff interviews (8) indicated that staff were not aware of any medication errors. Six resident interviews (6) expressed no concerns with medication administration. Based upon the information obtained during investigation, the above allegation is 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 conducted. Report left with facility. Unsubstantiated Staff do not provide adequate food service Based on eight staff interviews (8) and six resident interviews (6) and department observation of the kitchen and meal service, the department found that there was an adequate amount of food for the residents. The food appeared to look appetizing and nutritious, sanitation in the kitchen appeared appropriate, residents said food was good, and portions appeared plentiful. Food supplies in facility were adequate to meet the requirements. Currently, there is no evidence to suggest that staff have failed to provide adequate food service or provide it in a timely manner. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff do not properly maintain the facility grounds Based on eight (8) staff interviews, six (6) resident interviews, and department observation, the department observed the facility to be clean and sanitary. During department visits on several occasions, including on 10/07/25 and 10/14/25, the facility did not observe to be unsanitary including resident rooms, common areas and restrooms. Facility grounds were properly operating. Residents stated the caregivers clean the facility and take out the trash frequently. Residents stated that their hygiene, toileting, and laundering needs are being met and that housekeeping, and the staff, do a great job. Staff interviews indicated that the facility is kept clean and sanitary without any concern; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with Administrator.the state’s words, verbatim · CDSS document, Nov 24, 2025 · control 59-AS-20251006133416

Type of visit: Office

On 10/22/2025, around 09:30 AM, Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Lavinia Muscan were present for an informal meeting with Administrator Chad Rogers, Regional VP of Operations Terry Ervin, Senior VP of Health Services Jennifer Sato, Senior Regulatory Director Kevin Wrigley, and Nurse Jimmy Duong, which was held via Teams. During today's meeting, department discussed complaint history, including the complaint dated 09/25/2024. Facility representatives discussed the updated fall protocols for residents that are fall risks, such as: -Having an extensive fall mitigation program in place including an in-house rehab partnership that have led to a reduction in the severity and frequency of falls that take place. -Current Fall Risk Assessments and resident centered fall interventions on service plans for residents identified as fall risks. Ongoing team member training on identifying changes of condition related to fall risk and resident interventions. -Policies are in place to ensure that residents who suffer multiple falls receive additional fall reduction measures. In those cases where fall mitigation measures are no longer effective, we have policies in place to aid residents/families that help determine a care setting that will best meet the residents’ fall care needs. No deficiencies cited. Exit interview conducted. A copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Oct 22, 2025

Allegation investigated: Facility staff are not administrating residents’ medication as prescribed.

On 8/26/2025, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegation listed above and met with Administrator Chad Rogers. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Based on documents obtained and statements reviewed for August 2025, the department determined that there was insufficient evidence that any medication errors have occurred. Documents obtained show that all current medications were administered and logged correctly for residents per their doctor’s orders. Ten staff interviews (10) indicated that staff were not aware of any medication errors. Five resident interviews (5) expressed no concerns with medication administration. Based upon the information obtained during investigation, the above allegation is 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 conducted. Report left with facility. Unsubstantiated Facility is understaffed. Facility staff do not ensure that call pendants are in working condition. Based on interviews with ten (10) staff and five (5) residents, the Department determined that there are enough staff present to meet the needs of the residents in care and that residents are able to use the call buttons and receive help in a timely manner. Residents had no concerns with getting a hold of staff . Therefore, the allegations are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Facility staff does not ensure the facility is kept in clean sanitary conditions. Facility's laundry machine in disrepair. Based on ten (10) staff interviews, five (5) resident interviews, and department observation, the department observed the facility to be clean and sanitary. During department visits on several occasions, including on 08/11/25, the department did not observe any laundry machine being in despair. The facility did not observe to be unsanitary including resident rooms, common areas and restrooms. All facility washers were operating. Residents stated the caregivers clean the facility and take out the trash frequently. Residents stated that their hygiene, toileting, and laundering needs are being met and that housekeeping, and the staff, do a great job. Staff interviews indicated that the facility is kept clean and sanitary without any concern; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Aug 26, 2025 · control 59-AS-20250806151255

Allegation investigated: Facility is malodorous

On 8/26/2025, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to open complaint regarding allegation listed above and met with Administrator Chad Rogers. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Department investigated allegation, “Facility is malodorous”. The facility was toured on 8/26/2025 and several other occasions and observed to be clean, sanitary, and free from odor. Resident rooms, common areas, kitchen area, and dining room were toured. Four (4) staff members were interviewed in which they stated housekeeping and other staff keep the facility clean and free from odor. Staff stated due to resident incontinent care needs, at times there may be a temporary smell, but staff take care of the problem in a timely manner. Due to interviews and observation, the department finds allegation to be UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and report left with facility. Unfoundedthe state’s words, verbatim · CDSS document, Aug 26, 2025 · control 59-AS-20250821132626

Allegation investigated: Staff are not following universal precautions to ensure staff do not spread scabies

On 6/17/25, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Health Services Director Christina Del Rosario. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Based on observation, record review, and statement reviewed, the facility was following universal precautions. As a precaution, during the first sign of a rash, facility puts out PPE outside the resident room, notifies staff of the potential of scabies, and an in-service to staff is reviewed on proper handwashing and universal precautions. Facility encouraged resident to stay in their room during the episode. It was observed facility had required PPE outside the resident room; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility. Unfoundedthe state’s words, verbatim · CDSS document, Jun 17, 2025 · control 59-AS-20250606115602

Allegation investigated: Staff do not ensure the facility door is properly operating

On 6/17/25, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Health Services Director Christina Del Rosario. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Department observed the activation button for wheelchair accessible residents doesn't catch all the time. However, the door itself still automatically opens if it's pushed to trigger the door to open. Residents are not locked outside, and staff and residents are able to open and close by gently pressing on the door handle to activate the door to open automatically. Department observed other doors working from the courtyard, to get inside the facility. Department and the Administrator discussed plans to update the activation button for wheelchair accessible residents. Based on information obtained during the investigation, Department finds the allegations to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.Exit interview conducted. Report left with facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 17, 2025 · control 59-AS-20250527103015

Allegation investigated: Facility staff are not responding to call buttons in a timely manner

On 6/17/2025, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Health Services Director Christina Del Rosario. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: A sample of resident call button response logs was reviewed for April 2025. Based on call button logs, the typical response time for staff responding to a resident’s call alert ranges from 5–12 minutes. Residents interviewed stated they have not had issues with staff not responding to call buttons timely. Staff interviews indicated that staff usually respond to resident’s call buttons within 10-15 minutes. Staff did state that occasionally after assisting a resident, staff will forget to clear the call button request whereas documents may seem that residents are waiting for assistance longer. Based upon the information obtained during investigation, the above allegation is 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 conducted. Report left with facility. Unsubstantiated Facility staff are not allowing resident to move freely around the facility Based on observation, record review, and statements reviewed, the department determined that there was insufficient evidence that the facility does not allow residents to move freely around the facility. Based on four (4) staff interviews, four (4) resident interviews, and department observation, residents and staff stated that residents can move freely, and that staff help residents that need assistance who would like to move around the facility; therefore, the allegations are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Facility staff do not ensure that residents are delivered hot water throughout the facility Based on observation, record review, and statements reviewed, the department determined that there was insufficient evidence that the facility does not deliver hot water throughout the facility. Four (4) staff interviews and four (4) resident interviews state that there was never any problem with the facility hot water source; therefore, the allegations are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Facility staff interfere with resident receiving mail in a timely manner Based on observation, record review, and statements reviewed, the department determined that there was insufficient evidence that the facility interferes with residents receiving mail in a timely manner. Four (4) staff interviews and four (4) resident interviews state that they are not aware of any problems with receiving mail on time as the residents get their mail when they want. Lastly resident’s all have individual mailboxes where staff put resident’s mail when received. Residents did not indicate any issues with receiving their mail timely; therefore, the allegations are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Jun 17, 2025 · control 59-AS-20250502140534

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived on 6/17/2025 to conduct the annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed five resident (5) and five staff files (5). All resident files contained the required paperwork. All staff files contained the required paperwork. Facility was clean and well organized. Facility is current on fire drills. All required posting were observed. Staff training contained the required initial training. LPAs and Administrator Chad Rogers toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, dining room, hallways, and common areas. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. The disaster drill is current. The administrator's certificate is current. LPAs checked the kitchen area for the ability to prepare and store food. LPAs observed cleaning products and other toxins to be locked away. LPAs observed the area used for medication to be locked and inaccessible to residents. LPAs observed smoke detectors and carbon monoxide detector are operational. Fire extinguisher is ready for emergency use. Water temperature is within compliance. In the areas toured, there were no health or safety violations observed. LPAs requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by end of the month. Exit interview conducted. A copy of this report was printed and given to facility.the state’s words, verbatim · CDSS document, Jun 17, 2025

Allegation investigated: Questionable death Licensee does not ensure enough staff are present to meet the needs of the residents Staff did not seek timely medical attention for resident

On May 12, 2025, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Chad Rogers. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unfounded Questionable death Records were reviewed regarding the death of R5. Based on documentation, R5 was on Hospice at the time of death. Records indicated R5 had a family member present at the time of death on April 7, 2025. Family member noticed R5 was unresponsive and contacted facility staff. Facility staff contacted Hospice. Once Hospice arrived at the facility, R5 was unresponsive and pronounced deceased. R5’s death certificate lists cause of death as natural, therefore the above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Licensee does not ensure enough staff are present to meet the needs of the residents Staff did not seek timely medical attention for resident Based on interviews with four (4) staff and four (4) residents, the Department determined that there are enough staff present to meet the needs of the residents in care and that staff seek timely medical attention. Staff stated they know the protocol on how to address any medical intervention and residents had no concerns with timely medical attention. Therefore, the allegations are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, May 12, 2025 · control 59-AS-20250410120933

Allegation investigated: Staff mishandled a resident's medication while in care

On May 12, 2025, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Chad Rogers. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Based on documents obtained and statements reviewed for March/April 2025, the department determined that there was insufficient evidence that any medication errors have occurred. Documents obtained show that all current medications were administered and logged correctly for residents per their doctor’s orders. Four staff interviews (4) indicated that staff were not aware of any medication errors. Four resident interviews (4) expressed no concerns with medication administration. Based upon the information obtained during investigation, the above allegation is 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 conducted. Report left with facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 12, 2025 · control 59-AS-20250404095336

Allegation investigated: Staff did not attend to resident in a timely manner Resident pendants are in disrepair

On May 12, 2025, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Chad Rogers. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unsubstantiated Staff did not attend to resident in a timely manner Resident pendants are in disrepair A sample of resident call button response logs was reviewed. Based on call button logs, the typical response time for staff responding to a resident’s call alert ranges from 5–12 minutes. Residents interviewed stated they have not had issues with staff not responding to call buttons timely. Staff interviews indicated that staff usually respond to resident’s call buttons within 10-15 minutes. Staff did state that occasionally after assisting a resident, staff will forget to clear the call button request whereas documents may seem that residents are waiting for assistance longer. Based on records reviewed and interviews conducted, resident call pendant systems are operable, and staff are responding to residents in a timely manner. Based upon the information obtained during investigation, the above allegation is 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 conducted. Report left with facility. Facility is malodorous Facility bathroom is in disrepair Based on five staff interviews (5) and four resident interviews (4) and department observation, the department observed the facility to be clean and sanitary. During department visits on 03/06/25 and 04/14/25 the department did not observe any bathrooms in despair. The facility did not observe to be malodorous including resident rooms, common areas and restrooms. All facility bathrooms were operating and sanitary. Residents stated the caregivers clean the facility and take out the trash frequently. Residents stated that their hygiene, toileting, and laundering needs are being met and that housekeeping, and the staff, do a great job. Staff interviews indicated that the facility is kept clean and sanitary without any concerns; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff did not inform resident's representative of facility incident Based on documents obtained and statements reviewed, the department determined that the facility was following universal precautions for one resident with scabies. Staff is not required to notify anyone other than the resident’s family, unless there is an outbreak. Staff continued with proper hand washing and universal precautions. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Residents were not provided meals in a timely manner Based on five staff interviews (5) and four resident interviews (4) and department observation of the kitchen and meal service by the department found that there was an adequate amount of food for the residents. The food appeared to look appetizing and nutritious, sanitation in the kitchen appeared appropriate, residents said food was good, and portions appeared plentiful. Food supplies in facility were adequate per requirement. Currently, there is no evidence to suggest that staff have failed to provide adequate food service or provide it in a timely manner. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, May 12, 2025 · control 59-AS-20250319090333

Allegation investigated: Staff did not provide adequate supervision resulting in resident sustaining a fracture while in care. Staff did not prevent resident from suffering multiple falls while in care.

On April 8, 2025, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Chad Rogers. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Substantiated Staff did not provide adequate supervision resulting in resident sustaining a fracture while in care. Staff did not prevent resident from suffering multiple falls while in care. On July 16, 2024, R1 sustained a fall in the facility. Hospital medical records stated that on July 16, 2024, R1 sustained a broken left collarbone. Hospital Doctor confirmed that R1’s CT scan of spine showed a “comminuted left clavicular head fracture.” Doctor stated that the injury was an acute injury and was consistent with someone sustaining a fall. R1 reported they were in their room walking with their walker alone when R1 sustained a fall. R1 remembers bleeding “a lot” from their head. R1 did not know where facility staff were at the time of R1’s fall. File review documents do not document a specific fall plan for R1. A review of R1’s file indicated the facility conducted (2) two Reassessments on R1. Initial assessment at time of move in dated March 1, 2023, and June 20, 2024 due to a change in condition. R1 Needs and Service plans indicated R1 requires a personalized interventions per fall management protocol however the facility was unable to provide documentation with the personalized interventions the facility put in place to assist for R1. Facility staff interviewed reported that R1 sustained approximately 20 plus falls while at the facility. The facility did not have a clear plan in place to keep R1 from continuing to sustain these falls. Previous Administrator Lydia Gravelyn and another staff stated they believed R1 required a higher level of care than the facility could provide. R1 would constantly refuse care and assistance from facility staff, yet the facility allowed R1 to continue constantly falling while at the facility. The medical records obtained support that R1 sustained multiple falls resulting in head injuries and a clavicle fracture. Each fall was a result of R1 attempting to do things on their own rather than requesting assistance from facility staff. Facility file review records document R1 sustained 15 falls between 3/9/2023 and 7/16/2024. Facility failed to develop a personalized intervention plan as indicated in R1's needs and service plan resulting in R1 sustaining many falls at the facility including the fall R1 sustained on July 16, 2024, which caused R1 a serious injury. The above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. A civil penalty in the amount of $500 is assessed. The licensee was informed during today’s visit that a civil penalty is under review and may be assessed at a future date according to Health and Safety Code §1569.49. Exit interview conducted. Appeal rights provided. Report left with facility Administrator.the state’s words, verbatim · CDSS document, Apr 8, 2025 · control 59-AS-20240925193249

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463 · Plan of correction due date: Apr 9, 2025

Reappraisals (i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff... This requirement was not met based on the facility failed to ensure reassessments were conducted due to R1’s change in conditions. Additionally, the facility failed to develop a personalized intervention plan as indicated in R1's needs and service plan. This posed an immediate Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2025

Plan of correction: The administrator agrees to write a plan of correction detailing how facility will address reassessments for resident’s who are documented fall risks. Additionally, the facility agrees to submit a plan on how staff will be trained and notified of resident’s who are fall risks and fall prevention protocols for each resident.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2 · Plan of correction due date: Apr 9, 2025

Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met based on facility failed to ensure staff were trained on a personalized fall protocols for R1. This posed an immediate Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2025

Plan of correction: The administrator agrees to write a plan of corrections detailing how facility will address reassessments for resident’s who are documented fall risks.

Allegation investigated: Licensee does not ensure that residents' call pendant systems are operable. Licensee does not ensure that staff respond to residents' requests for assistance in a timely manner.

On March 5, 2025, Licensing Program Analyst (LPA) Lavinia Muscan and Licensing Program Manager (LPM) Laura Munoz arrived at the facility unannounced to investigate complaint regarding the allegations listed above and met with Administrator Chad Rogers. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unsubstantiated Licensee does not ensure that residents are provided with a comfortable temperature. Licensee does not ensure that the facility is kept clean and odor free Licensee does not ensure that staff follow proper sanitary food service protocols. Licensee does not ensure that food services provided to residents is adequate. Licensee did not ensure that resident received their mail. LPA and LPM conducted interviews and facility walk thru. Interviews with residents indicated resident’s have not had issues with the facility being at an uncomfortable temperature. Resident’s stated staff are consistent with cleaning their apartments as well as keeping common areas of the facility clean and sanitary. Resident’s stated they have not had issues with food service including temperature of food, quality and quantity of the food served. Lastly resident’s all have individual mailboxes where staff put resident’s mail when received. Resident’s did not indicate any issues with receiving their mail timely. During observations of the facility, LPA and LPM observed the facility clean and odor free. Facility was at a comfortable temperature during the visit. During the walk through of the facility kitchen area, LPA and LPM observed kitchen to be clean and sanitary. Food was observed to be labeled, covered and dated. Interviews with kitchen staff indicated food service staff have current food handler’s certificates. Based on interviews conducted and observation, the above allegations are found to be UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Questionable Death Records were reviewed regarding the death of R1. Based on documentation, R1 was on Hospice at the time of death. Records indicated R1 had a 1:1 aide (W1) present at the time of death. W1 noticed R1’s was unresponsive and contacted facility staff. Facility staff contacted Hospice. Once Hospice arrived at the facility, R1 was unresponsive and pronounced deceased. R1’s death certificate lists cause of death The above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility. Licensee does not ensure that residents' call pendant systems are operable. Licensee does not ensure that staff respond to residents' requests for assistance in a timely manner. A sample of resident call button response logs was reviewed. Based on call button logs, the typical response time for staff responding to a resident’s call alert ranges from 5–12 minutes. Residents interviewed stated they have not had issues with staff not responding to call buttons timely. Staff interviews indicated that staff usually respond to resident’s call buttons within 10-15 minutes. Staff did state that occasionally after assisting a resident, staff will forget to clear the call button request whereas documents may seem that resident’s are waiting for assistance longer. Based on records reviewed and interviews conducted, resident call pendant systems are operable and staff are responding to residents in a timely manner. Based upon the information obtained during investigation, the above allegation is 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 conducted. Report left with facility.the state’s words, verbatim · CDSS document, Mar 5, 2025 · control 59-AS-20250210105545

Allegation investigated: Staff are financially abusing a resident while in care Staff are not ensuring the residents are being properly fed

On 1/21/25, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Chad Rogers. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unfounded Staff are financially abusing a resident while in care Based on documents obtained and interviews conducted with eight (8) staff and six (6) residents, the department determined that residents have responsible parties who handle residents’ finances. Based on interviews and observation, department finds no evidence that staff in any way financially abuses any resident, therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff are not ensuring the residents are being properly fed Based on documents obtained and interviews conducted with eight (8) staff and six (6) residents, the department determined that residents are being properly fed. The food supply was observed to have two (2) days’ worth of perishable and seven (7) days’ worth of nonperishable as required. Staff and resident interviews indicated that residents are provided full meals for breakfast, lunch, and dinner, including snacks between meals and a bistro open all day, therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Jan 21, 2025 · control 59-AS-20241226113410

Allegation investigated: Residents contracted illness of unknown origin while in care.

On 1/21/25, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegation listed above and met with Administrator Chad Rogers. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.The results of the investigation are as follows: Based on documents obtained and interviews conducted with eight (8) staff and six (6) residents, the department determined that the facility had a stomach bug/flu outbreak that lasted 24-48 hours, not an unknown illness. The facility was following universal precautions. As a precaution, during any outbreak, an in-service to staff was done on proper handwashing and universal precautions. Facility encouraged residents to stay in their rooms during the stomach bug/flu outbreak. Any staff that experienced signs or symptoms were either sent home or told not to come into work until the symptoms subsided. It was observed facility had required posters posted throughout the facility regarding infection control guidelines and observed facilities supply of PPE, therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility. Unfoundedthe state’s words, verbatim · CDSS document, Jan 21, 2025 · control 59-AS-20241206203700

Allegation investigated: Medication errors

On 11/26/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Lydia Gravelyn. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Based on documents obtained and statements reviewed for August 2024, the department determined that there was insufficient evidence that any medication errors have occurred. Documents obtained show that all current medications were administered and logged correctly for residents per their doctor’s orders. Eight staff interviews (8) indicated that staff were not aware of any medication errors. Six resident interviews (6) expressed no concerns with medication administration. Based upon the information obtained during investigation, the above allegation is 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 conducted. Report left with facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 26, 2024 · control 59-AS-20240813084712

Allegation investigated: Staff are not ensuring that resident's hygiene needs are being met while in care. Staff are not ensuring that the facility is sanitary.

On 11/26/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Lydia Gravelyn. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unfounded Staff are not ensuring that resident's hygiene needs are being met while in care. Department conducted record review, staff, and resident interviews to investigate this allegation. Eight (8) staff interviews indicated that staff were providing all ADL assistance, including toileting to residents per their needs and service plan. Staff interviews indicated that staff were assisting residents for their toileting needs every 2 hours or as needed. Six (6) resident interviews reflected that their care needs were met by staff and there were no issues to address, therefore the above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff are not ensuring that the facility is sanitary. Based on eight staff interviews (8) and six resident interviews (6) and department observation, the department observed the facility to be clean and sanitary. During department visits on 8/20/24 and 10/2/24 the department did not observe any dirty bedding. The facility did not observe to be malodorous including resident rooms, common areas and restrooms. Residents stated the caregivers clean the facility and take out the trash frequently. Residents stated that their hygiene, toileting, and laundering needs are being met and that housekeeping, and the staff, do a great job. Staff interviews indicated that the facility is kept clean and sanitary without and concerns; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 59-AS-20240814161241

Allegation investigated: Staff mismanged resident's medication.

On 11/26/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Lydia Gravelyn. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. Based on documents obtained and statements reviewed for August 2024, the department determined that there was insufficient evidence that any medication errors have occurred. Documents obtained show that all current medications were administered and logged correctly for residents per their doctor’s orders. Eight staff interviews (8) indicated that staff were not aware of any medication errors. Six resident interviews (6) expressed no concerns with medication administration. Based upon the information obtained during investigation, the above allegation is 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 conducted. Report left with facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 26, 2024 · control 59-AS-20240820100045

Allegation investigated: Staff do not properly maintain the facility Staff do not keep the facility free from odor Staff did not provide adequate care and supervision to a resident

On 11/26/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Lydia Gravelyn. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unfounded Staff do not properly maintain the facility Staff do not keep the facility free from odor Based on eight staff interviews (8) and six resident interviews (6) and department observation, the department observed the facility to be clean and sanitary. During department visits on 9/18/24 and 10/2/24 the department did not observe any odor in the facility. The facility did not observe to be malodorous including resident rooms, common areas and restrooms. Residents stated the caregivers clean the facility and take out the trash frequently. Residents stated that their hygiene, toileting, and laundering needs are being met and that housekeeping, and the staff, do a great job, therefore, the allegations are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff did not provide adequate care and supervision to a resident Based on eight staff interviews (8) and six resident interviews (6) it was determined that residents are provided with adequate care and supervision. During the interview process it was reported that staff check on residents every two hours and as needed. It was reported that staff are conscience of keeping the residents clean and dry. Staff are aware of resident needs for adequate care and supervision per their needs and service plan. Resident interviews did not indicate any concern in proper care and supervision for residents by staff. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 59-AS-20240917004235

Allegation investigated: Staff does not keep the facility clean or sanitary Staff are not providing adequate food service Staff are not following precautions to mitigate the spread of COVID

On 11/26/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Lydia Gravelyn. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unfounded Staff does not keep the facility clean or sanitary Based on six staff interviews (6) and five resident interviews (5) and department observation, the department observed the facility to be clean and sanitary. During department visits on 10/8/24 and 11/19/24 the department did not observe any dirty bedding. The facility did not observe to be malodorous including resident rooms, common areas and restrooms. Residents stated the caregivers clean the facility and take out the trash frequently. Residents stated that their hygiene, toileting, and laundering needs are being met and that housekeeping, and the staff, do a great job. Staff interviews indicated that the facility is kept clean and sanitary without and concerns; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff are not providing adequate food service Based on six staff interviews (6) and five resident interviews (5) and department observation of the kitchen and meal service by the department found that there was an adequate amount of food for the residents. The food appeared to look appetizing and nutritious, sanitation in the kitchen appeared appropriate, residents said food was good, and portions appeared plentiful. Food supplies in facility were adequate per requirement. Currently, there is no evidence to suggest that staff have failed to provide adequate food service. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff are not following precautions to mitigate the spread of COVID Based on documents obtained and statements reviewed, the department determined that the facility was following universal precautions. As a precaution during COVID outbreak an in-service to staff was done on proper handwashing and universal precautions. Any staff that experienced signs or symptoms were either sent home or told not to come into work until the symptoms subsided. Facility kept a log of all staff that was sick and when the symptoms resolved, and they could return to work. It was observed facility had required posters posted throughout the facility regarding infection control guidelines and observed facilities supply of PPE. Additionally, when staff returned to work staff was to wear a mask for the first few days therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 59-AS-20241003162836

Allegation investigated: Staff are not preventing a resident from being abused by another resident while in care.

On 11/26/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Lydia Gravelyn. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. Based on documents obtained and statements reviewed it was determined that both R1 and R2 are independent, and they do not want anyone interfering in their personal lives. Based on five staff interviews (5) it was determined that this is how the couple has always acted with each other. Staff have not observed any physical violence and stated that this couple is one of their favorite couples. R1 stated that R1 does not feel abused by R2. R1 stated that this is R2’s personality, and it has been all R2’s life, and that everyone needs to stay out of their personal business. R1 stated that R2 is just loud. Based on this, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility. Unfoundedthe state’s words, verbatim · CDSS document, Nov 26, 2024 · control 59-AS-20241010163558

Allegation investigated: Staff are financially abusing residents

On 11/26/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Lydia Gravelyn. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. Based on documents obtained and statements reviewed it was determined that facility does not financially abuse residents. Based on five staff interviews (5) and five resident interviews (5) and department observation it has been determined that the Resident Council is the one who sets up a surprise fund for the front-line workers, every year for winter Holidays. Staff are not involved in the Resident Council and therefore have no idea what the Resident Council does. Furthermore, resident interviews indicated that their participation in that event was volunteer. Based on this information, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility. Unfoundedthe state’s words, verbatim · CDSS document, Nov 26, 2024 · control 59-AS-20241118114348

Allegation investigated: Staff is sleeping during the evening hours Staff leaves the residents soiled while in care Staff leaves the residents unattended

On 9/4/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Regional Nurse Jimmy Duong. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unfounded Staff is sleeping during the evening hours - UNFOUNDED Based on interviews and record reviewed, it was determined that, although one person was in fact sleeping on duty on the evening shift, there were still 3 other Med Tech/Caregivers on duty and awake at the night. There is not a regulation that strictly prohibits staff sleeping. The regulations governing night supervision, 87451 (a)(2) states: "In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes." Therefore, no regulation has been violated at this time. The above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff leaves the residents soiled while in care -UNFOUNDED Staff leaves the residents unattended -UNFOUNDED Based on records reviewed and interviews, care plans are followed and implemented by staff. Department observed residents in care have care plans that are up to date and address their care needs as documented. Staff interviewed were able to demonstrate knowledge of how to implement assistance identified in the care plan. Eleven (11) staff interviews indicated that staff were providing all ADL assistance, including toileting to residents per their needs and service plan. Staff interviews indicated that staff were assisting residents for their toileting needs every 2 hours, or as needed, therefore the above allegations are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview was conducted with staff and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 59-AS-20240603234144

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lavinia Muscan arrived on 7/1/2024 to conduct the annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (8) and staff files (6). All resident files contained the required paperwork. All staff files contained the required paperwork. All staff have current first aid and CPR training. Facility was clean and well organized. Facility is current on fire drills. All required posting were observed. Staff training contained the required initial training. LPA and Administrator Lydia Gravelyn toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, dining room, hallways, and common areas. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. The disaster drill is current. The administrator's certificate is current. LPA checked the kitchen area for the ability to prepare and store food. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector are operational. Fire extinguisher is ready for emergency use. Water temperature is within compliance. In the areas toured, there were no health or safety violations observed. LPA requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by end of the month. Exit interview conducted. A copy of this report was printed and given to Administrator.the state’s words, verbatim · CDSS document, Jul 1, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced on 6/3/24 to do a case management visit. LPA met with Health Services Director Stephanie Williams and explained the purpose of the visit. Department followed up on an Incident report that happened on 5/18/24. Incident report sent into the department on 5/21/24. R1 was having dinner in the dining room when R1 appeared to be choking. Staff was called and performed the Heimlich maneuver, then chest compressions. Additionally, 911 was called. R1 passed 5/18/24. LPA received all documents requested. At this time, this case in under review and department will follow up as needed. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, Jun 3, 2024

Allegation investigated: Staff do not respond to residents' call buttons in timely manner

On 5/1/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Lydia Gravelyn. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unsubstantiated Staff do not respond to residents' call buttons in timely manner The department conducted staff and residents' interviews, reviewed records to investigate the allegation. During interviews, staff stated that staff respond to resident call buttons in a timely manner, however, sometimes there is a delay in response due to staff assisting other resident’s needs. During facility observation and call log review for November 2023, the department did not observe any long/extended wait times from staff to respond to resident's call button, therefore this allegation is found to be 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 was conducted with Administrator and a copy of this report was provided to the facility. Staff do not ensure residents have adequate night time supervision From the record review, LPA has reviewed facility schedules, and observed that shifts were covered by multiple staff. There was no evidence to support the allegation that there was not adequate nighttime supervision. LPA learned that there were at least 2 direct care staff working on each floor during each shift. Five (5) resident interviews indicated that their care needs are met and there were no issues regarding nighttime supervisor at facility. Based on this information, LPA finds no evidence that the current staff level is insufficient. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff did not meet resident's toileting needs. Department conducted record review, staff, and resident interviews to investigate this allegation. Nine (9) staff interviews indicated that staff were providing all ADL assistance, including toileting to residents per their needs and service plan. Staff interviews indicated that staff were assisting residents for their toileting needs every 2 hours or as needed. Five (5) resident interviews reflected that their care needs were met by staff and there were no issues to address, therefore the above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview was conducted with Administrator and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, May 1, 2024 · control 59-AS-20231114150643

Allegation investigated: Staff dose not ensure medication records are properly maintained for residents in care

On 11/8/23, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Lydia Gravelyn.During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.The results of the investigation are as follows: Staff dose not ensure medication records are properly maintained for residents in care Based on documents obtained and statements received, the department determined that there was insufficient evidence that staff did not properly maintain medication for residents in care. Documents obtained show that all current medications were administered and logged correctly and were given to residents per their doctor's orders. Based upon the information obtained during investigation, the above allegation is 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. Report left with facility. Unsubstantiated Staff did not seek treatment in a timely manner for resident in care Based on documents and interviews, R1 developed a rash from a cream R1 was using. The facility was in contact with R1’s doctor regarding the rash. R1’s doctor prescribed the use of a different cream. R1 has been under treatment for skin rashes for many years. R1 had an outbreak of a skin rash which was addressed with R1’s doctor timely; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff does not ensure care plan is followed for resident Based on records reviewed and interviews, care plans are followed. LPA observed residents in care have care plans that are up to date and address their care needs as documented. Staff interviewed were able to demonstrate knowledge of how to implement assistance identified in the care plan, therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Facility overcharges resident for services not provided Based on records reviewed and interviews, the admission agreement for R1 is observed to be followed. LPA observed no extra charges outside of what is identified and agreed upon in R1’s care plan, which is up to date, and addresses residents’ care needs as documented, therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff do not ensure effective communication is conducted with residents responsible party Based on records reviewed and interviews, it was determined that the facility was in contact with the resident’s responsible party. Emails, texts, and calls exchanged by both parties were reviewed; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview. Report left with facility.the state’s words, verbatim · CDSS document, Nov 8, 2023 · control 59-AS-20230922122436

Allegation investigated: Staff did not dispense medication to resident as prescribed.

On 10/30/23, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Lydia Gravelyn. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.The results of the investigation are as follows: Staff did not dispense medication to resident as prescribed. Based on documents obtained and statements received, the department determined that there was insufficient evidence that staff did not dispense medication to residents as prescribed. Documents obtained show that all current medications were administered and logged correctly and were given to residents per their doctor's orders. Based upon the information obtained during investigation, the above allegation is 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 was conducted with Administrator and a copy of this report was provided to the facility. Unsubstantiated Staff did not follow resident's diabetic diet. Department conducted interviews with residents and staff to investigate this allegation. Interviews indicated that residents were happy with dietary services at the facility and did not indicate any issues. Based on the record review for R1’s physician's reports and review of preadmission records, there are no dietary restrictions for R1, therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff did not follow resident's care plan.Based on records reviewed and interviews, care plans are followed. LPA observed residents in care have care plans that are up to date and address their care needs as documented. Staff interviewed were able to demonstrate knowledge of how to implement assistance identified in the care plan, therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff did not adequately supervise resulting in residents wandering into resident's room and not leaving.Based on interviews it was determined that residents in memory care that wander in other resident’s bedrooms are redirected back to their own rooms by staff. If residents continue to wander in other residents’ rooms, the doors are then locked from the outside so that residents cannot have access to other residents’ rooms. Residents' rooms have self-unlocking doors from the inside allowing residents to leave their room freely. Staff are aware of wandering in the memory care unit and address the issue as needed, therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff did not provide resident a method of calling for assistance. Based on interviews and observation, the department finds that there are call buttons in all residents’ rooms as well as the option to wear a call button on your person. Residents and staff interviews did not indicate any issues with call light/button system at facility, therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff did not meet resident's hygiene needs. Staff did not meet resident's dental care needs. Staff did not maintain resident's bathroom in a clean and sanitary condition. Staff did not meet resident's toileting needs. Staff did not meet resident's laundering needs. Based on interviews and observation, the department observed the facility to be clean and sanitary. During department visits on 10/11/23 and 10/18/23 the department did not find any dirty bedding. The facility did not observe to be malodorous including resident rooms, common areas and restrooms. Residents stated the caregivers clean the facility and take out the trash frequently. Residents stated that their hygiene, toileting and laundering needs are being met and that housekeeping, and the staff, do a great job, therefore, the allegations are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview was conducted with Administrator and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 30, 2023 · control 59-AS-20231003142229

Allegation investigated: Resident left in soiled diapers for extended amount of time. Staff are not providing showers to residents in care. Staff do not respond to call bells in a timely manner.

On 10/11/23, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Lydia Gravelyn. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unfounded Resident left in soiled diapers for extended amount of time. Department conducted interviews with staff and residents, records were reviewed, and facility observation was done to investigate this complaint allegation. Staff and residents interviewed on 9/12/23 indicated that staff were providing incontinence care to residents every 2 hours or as needed per their needs and service plan. Residents interviewed indicated that staff were not leaving them soiled for long times and staff aid with their incontinence care needs as needed. Based on this information, this allegation was found to be UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff are not providing showers to residents in care. Regarding the allegation that residents do not receive showers, LPA has toured the facility, met with several residents, spoken with staff, and reviewed documentation. In meeting with residents, all appear to be clean and groomed. In speaking with staff, LPA learned that residents are on a schedule to shower twice a week, some more often, depending on individual needs. Residents sometimes refuse to have a shower, and staff will then make several attempts during the shift to get them to shower, by trying later, having a different person try, etc. If the person does not have a shower when scheduled, staff let the next shift know. Overall, residents receive showers on a regular basis. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Staff do not respond to call bells in a timely manner. The department conducted staff and residents' interviews, reviewed records to investigate the allegation. During residents’ interview, residents stated that staff respond to their call buttons in timely manner however sometimes there is a delay in response due to staff assisting other resident’s needs. During call button log review, the department did not observe any long/extended wait times from staff to respond to resident's call button, therefore this allegation is found to be UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left at facility.the state’s words, verbatim · CDSS document, Oct 11, 2023 · control 59-AS-20230710132730

Allegation investigated: Staff gave resident another resident's medication

On 10/11/23, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to open and deliver complaint findings into the allegations listed above and met with Administrator Lydia Gravelyn. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unfounded Staff gave resident another resident's medication Based on documentation reviewed and conversation with the facility representative, on 10/6/23, the facility received a medication delivered for R1 from PharMerica pharmacy. The medication bottle had R1’s name and information. The medication was for an antibiotic and not routine medications for R1. R1 was administered 4 days of the prescribed medications. R1’s responsible party (RP) was at the facility and was told the facility administered the medication to R1. R1’s RP questioned the facility why R1 was being administered an antibiotic because R1 was not prescribed the medication by their physician. Upon further investigation, the facility learned that PharMerica pharmacy labeled the medication incorrectly with R1’s information however the medication was for another individual. Once this was learned, the facility ceased administering the medication to R1 and R1’s physician was notified. R1 did not experience any side effects due to being administered this medication. Although the facility administered a medication that was not prescribed to R1, the medication was incorrectly labeled by the pharmacy therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left at facility.the state’s words, verbatim · CDSS document, Oct 11, 2023 · control 59-AS-20231005145435