Oakmont of Fair Oaks

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection and met with Tammy Smith, Memory Care Specialist and Alexis Mendoza, Memory Care Director. LPA stated the reason for today's inspection. Administrator, Anyssa Hill, arrived around 1:30 pm. The facility is licensed for (128) non-ambulatory residents, (8) of whom may be bedridden. There is an approved hospice waiver for (8) residents. Currently, there are (7) residents under hospice care. LPA, Memory Care Specialist, and Memory Care Director toured the common areas of Assisted Living Unit (ALU), including the dining room, main kitchen, enclosed patio, bistro, movie theater, and (2) resident rooms and the Memory Care Unit (MCU). All areas toured were observed to be clean, in good repair and odor free. The hot water temperature was tested in (2) resident rooms and measured 115*F in one room and 119*F in another, within the 105-120*F range. The egress door was tested in Memory Care and staff responded quickly. Inside temperature measured 72*F, and the fire extinguishers were last serviced 2/19/2026. There was 2+day perishable, including fresh produce, and 7+day non-perishable food on site. LPA observed one of two weekly food deliveries. Facility bus maintenance records were reviewed and found to be current. LPA reviewed (3) Memory Care resident files and (5) Assisted Living resident files. Files are well organized and contain required/current documentation. Medications were checked for (2) residents in ALU and MCU each. Medications are being administered per orders and documentation is being maintained accurately. (8) staff files were reviewed. Staff is regularly completing required training through an approved vendor. Staff have current First Aid/CPR certifications. Administrator has RCFE Administrator Certificate #6076929740 (exp 7/9/27). There were no deficiencies observed during today's inspection. Exit interview. Copy of report provided to Executive Director.the state’s words, verbatim · CDSS document, Jul 15, 2026

Allegation investigated: Facility has insufficient staff to meet the care needs of the residents.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to continue the investigation and met with Administrator, Pouya Ansari and Business Office Director, Habi Torres. LPA stated the reason for today's inspection. During the investigation, the Department interviewed the Administrator, the Health and Services Director/Licensed Vocational Nurse (LVN), multiple facility staff and (2) famil members of resident (R1). The Department reviewed documentation, including (R1's) Physician's Report, care plans, Medication Administration Records (MAR), charting notes and incident report (LIC624). The results of the investigation are as follows: Resident (R1) moved to the community in June 2022 and transferred to the Memory Care Unit (MCU) in 2024. The Physician's Report (10/15/2024) notes a diagnosis of: a fall, Left Femoral Neck Fracture, Dementia, incontinent with bladder, confused/disoriented, unable to transfer independently. *cont on 9099C-1.. Unsubstantiated 90099C-1.. Allegation: Facility has insufficient staff to meet the care needs of the residents. The allegation states the facility did not provide sufficient staffing which resulted in (R1) falling, breaking their hip and requiring a wheelchair. The Administrator confirmed that (R1) did not have a fall in January 2026, when the complaint was filed, but had a fall in October 2024 which resulted in a change in condition. The Administrator confirmed (R1) still uses a wheelchair, has been on fall management following the fall on October 9, 2024, and (R1) was sent to the Emergency Room after this fall due to complaining of pain. The incident report completed and submitted to the Department on October 11, 2024, notes (R1) was sent to the Emergency Room (ER) due to (R1) complaining of “lower extremity pain with movement”. The charting notes state that on October 9, 2024 (8:04 pm), (R1) had an unwitnessed fall in the common area/dining room and that the family member was contacted and requested to be notified if (R1) needs to go the ER. The subsequent entry indicates that (R1) was sent out to the Emergency Room on October 10, 2024 (8:14 pm) per the family member’s request due to resident stating they were in pain and not being able to move their left side. (R1) returned from the hospital on October 15, 2024 (6:00 pm). The LVN stated she was not at the community when (R1) fell on October 9, 2024, as it occurred around 8:00 pm after her shift ended. Two Med-Tech staff who work “am” shift stated they didn’t recall the fall (R1) had on October 9, 2024 (8:00 pm) but recalled (R1) being at the hospital and then returning in a wheelchair. These staff indicated (R1) has had no other serious falls or any pressure wounds. A family member stated that "(R1) wasn't using a walker as a habit" which contributed to the fall, and "staff were instrumental in getting (R1) to recover better". This family member commented that she observed there to be sufficient staffing each day of the week when visiting (R1). Staffing schedules reflected (4) care staff and (1) Med-Tech scheduled on am/pm shifts and (3) care staff scheduled on NOC shift for approximately (32) residents residing in MCU. The care plan in place at the time of the fall indicated that Resident is at risk for falling and requires staff observation to promote safety, but does not require use of an assistive device. The care plan was updated on 11/14/2024 and reflected an increase in care (R1)requires total assistance with dressing, feeding, toileting, transferring, escorting (wheelchair). Remains on Fall Management. Based on information obtained, the department finds the allegation 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. 9099A-C-1- Allegation: Facility staff are mismanaging resident's medications. The allegation states that (R1) has erratic medication delivery and is not administered medications regularly as ordered. LPA asked the Licensed Vocational Nurse (LVN) about medications arriving at different times and possibly being missed. The LVN stated (R1) was on hospice previously, graduated in 2025, and their medications from their health care provider are repackaged in bubble packs. The LVN stated she does medication audits weekly, and there have been no errors with (R1’s) medications. A Med-Tech stated she administers medications to (R1), there are "no issues", and there is a crush order in place. Thie Med-Tech confirmed (R1’s) medications are ordered through an in-house pharmacy and (R1’s) family member also brings in some medication bottles from (R1’s) health care provider, and the facility will send the medications to the in-house pharmacy so they can package them in bubble packs. This Med-Tech indicated medication refills with the health care provider are usually 90 days, and they are 30-60 days with the in-house pharmacy, so they always have extra on hand, and (R1) never runs out. A second staff who works as a Med-Tech indicated that there is a crush order on file and there are no issues with (R1) taking medications A family member of (R1) who visits multiple times each week indicated that there are no missed medications or late refills and commented that she "brings extra medications" to the facility. This family member explained that the refill process has changed recently- sometimes she orders medications through the primary health provider, and the in-house pharmacy can do so also. LPA reviewed copies of the MAR from Jan- Mar 2026 for (R1). All months showed (4) scheduled medications were administered as ordered; and (1) PRN administered- Trazadone 25 mg, was administered several times and documented as required, including if the medication was effective. Based on information obtained, 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. *cont n 90909A-C2.. 9099A-C-2.. Allegation: Facility is not ensuring adequate food services for the residents in care. The allegation states the food served in the Memory Care Unit (MCU) is unsatisfactory in amount and quality compared to what is served on the assisted living unit (ALU). Additionally, (R1) may not be receiving what is necessary to keep her healthy. A family member stated she believes there are enough options, there are always sandwiches available at every meal, and the portions are usually fine. Additionally, this family member stated staff were “instrumental in getting (R1) to recover better” and (R1) enjoys the Boost shakes staff provide with medications. Multiple staff stated that MCUt has the same menu as ALU, but the food is not presented the same. In MCU, the food is not plated ahead of time but right before it's served. Additionally, staff indicated that water is served with all meals, water pitchers are delivered with the food on the carts from the main kitchen, staff will consider resident's dietary restrictions, and residents can order sandwiches too as an alternative to the daily special. A Med-Tech staff stated (R1) "doesn't need pureed food and can eat solids, salads, fries and likes sweets", and all staff indicated that (R1) requires assistance with feeding, but eats well. This staff indicated she doesn't see a difference in the serving size in MCU than what is served in ALU, but ALU is more like a restaurant with more menu choices. Staff confirmed fruit is always served with breakfast, salads for lunch and staff make smoothies to offer residents for snack time. LPA observed Smoothies to be the morning snack item on 3/25/26. The LVN stated (R1) "started improving a lot because they ate and drank better and had feeding assistance and confirmed residents are given fruit smoothies every afternoon. The LVN explained that the ALU kitchen makes the same food for MCU, and staff know each resident individually so they know how much to serve them, commenting that the resident can always have second portions, and there are (3) snacks served daily. Care Plan dated 11/14/2024- reflects increased care needs, including requiring total assistance with feeding The chef stated that there is a menu the facility follows daily, and it is the same for ALU and MCU and explained the daily special is changed as well as the weekly special. The chef explained that residents in ALU "pre-order" their food as they are able to read and order from the menu and stated the main kitchen will send food in a hot box to MCU. The Chef confirmed that all food is ordered from the same vendor, and 95% of the food is made from scratch", and commented, "most people eat whatever the special is and we plate everything the same". *cont on 9099A-C-3.. 9099A-C-3..The Chef was asked about the quantity of food served in MCU and ALU and replied "Yes, memory care residents don't eat as much- the food served in ALU is presented a little differently”. Additionally, staff do take orders in MCU and will ask residents what they want, complete an order paper, and check if there are any variations such as vegetarian or if proteins need to be cut in a smaller size, commenting, “the kitchen knows what it is preparing". On March 25, 2026, LPA observed (R1) to be sitting/sleeping in her wheelchair at the end of the bar/counter and resting after just finishing lunch. The staff who assisted (R1) with feeding on March 25, 2026, indicated that (R1) had a quesadilla, some French fries and a bowl and a half of soup for lunch today. LPA confirmed the daily lunch special on April 2, 2026- in ALU and MCU was Ultimate Veggie Pizza. There are two dinner specials today, in ALU and MCU- Tilapia with rice and Indian vegetable Samosas. The breakfast special today was Chef's Omelette Based on information obtained, the allegation is determined to be A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Allegation: False claims. The allegation states that the facility advertises it has a nurse, but a nurse has never been seen when visiting the facility. The facility Administrator confirmed the facility has a nurse, who is the Health and Services Director, and she is on site 5 days/week, and on-call- Sundays through Thursdays. LPA interviewed the Licensed Vocational Nurse (LVN) who works at the facility. The LVN stated she works at the facility from Sunday through Thursday, and sometimes on Saturdays, and confirmed she is the only nurse currently working at the facility. The LVN stated she has interacted with both of (R1’s) family members who regularly visit (R1) during the 1.5 years she has worked at this location. A family member indicated that she always sees this LVN at the facility when she visits weekly. Based on information obtained, the allegation is determined to be 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. Copy of report emailed.the state’s words, verbatim · CDSS document, Apr 2, 2026 · control 59-AS-20260105150814

Type of visit: Office

A follow-up meeting to a non-compliance conference was conducted today via Microsoft Teams. The purpose of this conference meeting was to address the facility's compliance following a non-compliance conference conducted on June 19, 2025 due to receiving 7 Type A citations and 23 substantiated complaint allegations since being licensed July 27, 2021. Present in the meeting was CCLD staff, including Licensing Program Manager Lauren Crocker and Licensing Program Analyst Michael Hood, and facility representatives, including the Administrator/Executive Director Pouya Ansari and Vice President of Operations Terry Ervin. The conference process was explained during this meeting. Topics discussed during this meeting were: · Facility's ongoing compliance since non-compliance conference conducted on June 19, 2025 · Result of assistance from Technical Support Program · Resources for technical support The facility is doing the following to achieve continued and substantial compliance: · Open communication between the facility and the Department regarding any future concerns to ensure ongoing compliance Facility representatives were informed that LPA will continue increased monitoring at the facility to ensure ongoing compliance as deemed necessary. An exit interview was conducted and a copy of this report will be provided to the facility via email. A copy must be signed and returned to CCLD.the state’s words, verbatim · CDSS document, Feb 6, 2026

Type of visit: Case Management - Other

On January 6, 2026, Licensing Program Analyst (LPA) Michael Hood met with Facility Representative Pouya Ansari for an unannounced inspection to follow-up on substantiated complaints. On August 29, 2023, the Department concluded a complaint investigation regarding the following allegations: Resident sustained pressure injuries while in care and the facility did not seek timely medical care for pressure injuries. The licensee was cited for California Code of Regulations (CCR) Title 22, §87466 Observation of Resident, and CCR Title 22, §87465(a)(1) Incidental Medical and Dental Care. On August 29, 2023, the issuance of an immediate civil penalty for $500 was issued and Licensee was informed that a civil penalty per Health and Safety Code §1569.49(f) is under review, and a determination is pending. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of 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 proper care and supervision resulting in a resident (R1) being diagnosed with multiple unstageable pressure injuries that required hospitalization, wound care, and antibiotics. ** Report continued on 809-C ** Today, January 6, 2026, the Department will be issuing a civil penalty per Health and Safety Code §1569.49(f) in the amount of $10,000 for a violation that the Department constitutes as serious bodily injury. However, since an immediate civil penalty of $500 was issued on August 29, 2023, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Pouya Ansari and signature on this report acknowledges receipt of the appeal rights found on page two (2) of the LIC 421D.the state’s words, verbatim · CDSS document, Jan 6, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Pouya Ansari, to conduct a case management health and safety check. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA reviewed five (5) staff files during visit and observed staff in the process of completing necessary training for 2025. LPA conducted a medication count for six (6) residents, comparing each resident’s Centrally Stored Medication Form (CSMF) with medications centrally stored for the resident. LPA observed medications given as prescribed. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit was interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Dec 30, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analysts (LPAs) Michael Hood and Marisa Chiarelli arrived at the facility and met with Executive Director (ED), Pouya Ansari, to conduct a case management health and safety check. LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPAs toured facility during inspection. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit was interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Dec 18, 2025

Allegation investigated: Staff did not seek medical attention for resident in a timely manner.

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Pouya Ansari, to deliver findings into the complaint allegation listed above. During the course of the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Staff did not seek medical attention for resident in a timely manner. ** Report continued on 9099-C ** Unsubstantiated Relevant party reported that something had happened to resident (R1) prior to May 25, 2025, when R1 was hospitalized and facility staff did not report changes to R1's authorized representative. LPA conducted interviews with seven (7) staff members, including the Memory Care Director (MCD), who all claimed they noticed a decline in R1 a month or two (2) prior to R1's May 25, 2025 hospitalization. R1 was reported to be moving slower, not eating as much, and not participating in their usual activities. R1's decline was reported to be slow and gradual. Interviews with staff attributed these changes to R1’s dementia diagnosis. Observations made by staff were reported to the Med-Techs and the MCD. MCD claimed that R1 was not sick until the day R1 was sent out to the hospital. MCD stated that, at that time, “everyone” was having a cold in the Memory Care Unit (MCU). R1 had two (2) “accidents” of incontinence which is “out of the ordinary” for R1. MCD confirmed that they were made aware by staff of the changes noticed in R1 and that family and doctor were aware of the changes in resident’s eating habits. On May 25, 2025, R1 was admitted for (but not limited to) the following: o Acute metabolic encephalopathy (brain dysfunction caused by an underlying condition. The underlying condition can cause a chemical imbalance in the blood. As a result, the brain doesn’t get what it needs to function as expected. Metabolic encephalopathies usually develop acutely or sub acutely and are reversible if the systemic disorder is treated. If left untreated, however, metabolic encephalopathies may result in secondary structural damage to the brain.) o Severe sepsis (a serious condition in which the body responds improperly to an infection. The infection-fighting processes turn on the body, causing the organs to work poorly. Sepsis may progress to septic shock – a dramatic drop in blood pressure that can damage the lungs, kidneys, liver and other organs. When the damage is severe, it can lead to death) secondary to community-acquired pneumonia o Mass in the left mid lung (previously noted on R1's previous hospitalization on March 5, 2024). R1 completed a five (5) day course of antibiotics for pneumonia. After discussions of need for lung mass biopsy and risks of potential chemotherapy, R1's family decided to not pursue biopsy. During R1's admission, R1 was noted to be an aspiration risk, and R1 was made NPO (nothing by mouth). Repeat evaluation allowed upgrade to a dysphagia diet, but R1 remained with poor oral intake due to lack of appetite. Family was not interested in artificial nutrition or feeding tube. After palliative and hospice team discussions, family decided on hospice. R1 was discharged on hospice on May 30, 2025. ** Report continued on 9099-C ** Relevant party also reported concerns regarding potential neglect resulting in an incident on March 5, 2024. Per incident report received by the Department, R1 was experiencing cough and was advised to be sent out to ER via ambulance. R1's authorized representative was notified. R1 was admitted and went back to the facility on March 8, 2024 with oral antibiotics. A follow up visit by R1's primary care physician was conducted on March 11, 2024. Medical records for March 5, 2024 incident indicate that R1 presented with shortness of breath and hypotension concerning for underlying pneumonia versus urinary tract infection meeting criteria for sepsis. A 10 mm nodule midlung is nonspecific and not seen on previous exams. R1 was treated with antibiotics and fluids and discharged back to facility on March 8, 2024. R1 was noted with cognitive and physical changes one (1) to two (2) months prior to their hospitalization on May 25, 2025. All staff interviewed noted the changes to be slow and gradual. As claimed by MCD, family and doctor were made aware. R1 was sent out by facility when resident was experiencing acute changes, and R1's family was also notified. Based on the medical records in the hospital, resident was admitted for (but not limited to) acute metabolic encephalopathy, severe sepsis secondary to community-acquired pneumonia, and mass of upper lobe of left lung. There is no evidence that R1 was neglected by facility for this incident. As for the incident on March 5, 2024, there is no specific evidence that R1 was neglected by facility. LPA conducted an interview with R1's authorized representative, who confirmed that facility reported changes in R1's condition. LPA conducted interviews with residents R1, R2, R3, R4, R5, and R6 during investigation. R2, R3, R4, R5, and R6 stated that they are treated well by facility staff and that their care needs are being met. R2, R3, R4, R5, and R6 stated that they have not witnessed any residents in need of care and not receiving assistance from facility care staff. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegation is 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 was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Sep 30, 2025 · control 59-AS-20250528102331

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Pouya Ansari, to conduct a case management health and safety check. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA reviewed five (5) staff files during visit and observed staff in the process of completing necessary training for 2025. LPA conducted a medication count for four (4) residents, comparing each resident’s Centrally Stored Medication Form (CSMF) and Medication Administration Record (MAR) with medications centrally stored for the resident. LPA observed medications given as prescribed. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit was interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Sep 29, 2025

Allegation investigated: Facility staff are mismanaging residents' medication

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Pouya Ansari, to deliver findings into the complaint allegation listed above. During the investigation, LPA conducted a medication count, conducted interviews, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Facility staff are mismanaging residents' medication ** Report continued on 9099-C ** Substantiated LPA reviewed an Unusual Incident/Injury Report (SIR) for resident (R4) dated October 22, 2024 for an incident that occurred on October 21, 2024 regarding a medication error. SIR states that, on October 21, 2024, while conducting a weekly self Audit of the Assisted Living Med-Room, it was discovered by Health Services Director (HSD) that an order of Prednisone was being given to R4 incorrectly. Facility reported that the medication order was placed in the facility’s medication administration record from the pharmacy and an additional order on paper was placed in the system by a previous Director. One order stated morning dosage, and the second order stated evening dosage, creating confusion and wrong dosages given from September 22, 2024 to October 18, 2024. Upon discovery, the order was corrected and given as prescribed following correction. SIR states that facility would continue doing weekly audits of the Med-Room, HSD would be approving all orders, and an in-service training would be completed with Med-Techs. On June 3, 2025, LPA conducted a medication count for residents R1, R2, and R3, comparing each resident’s Centrally Stored Medication Form (CSM) and Medication Administration Record (MAR) with medications centrally stored for the residents. LPA observed two (2) of five (5) medications for R1 were over the amount documented by two (2) tabs. After missed passes were factored into count, R1's MAR did not include any additional information to justify the two (2) medications over by two (2) tabs. LPA observed four (4) of five (5) medications for R2 to be off-count in relation to the amount documented. One (1) medication for R2 should have been finished and still had four (4) tabs available, one (1) medication was over by one (1) tab, one (1) medication was over by four (4) tabs, and one (1) medication was under by 20 tabs. R2's MAR did not indicate any refusals or missed passes of medication, nor did it indicate any reason for medications to be under the amount documented. LPA observed three (3) of seven (7) medications for R3 to be off-count in relation to the amount documented. One (1) medication for R3 should have been finished and still had nine (9) tabs available, one (1) medication was over by two (2) tabs, and one (1) medication was over by three (3) tabs. R3's MAR did not indicate any refusals or missed passes of medication, nor did it indicate any reason for medications to be under the amount documented. Based on medication count and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is 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. Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents. Interviews with staff members S1, S2, S3, S4, S5, S6, and S7 indicated that they have never observed a resident in need of care and not receiving assistance from facility care staff. Interviews with residents R3, R5, R6, R7, and R8 indicated that they are treated well by facility staff and that their care needs are being met. Interviews with residents did not indicate any concerns regarding care staff providing assistance with ADLs. Interviews with residents indicated that they did not witness any residents in need of care and not receiving assistance from facility care staff. Interview with R3's authorized representative indicated that they have no concerns regarding care being provided to R3 and they felt caregivers do a good job providing care at the care home. During visits conducted on June 3, 2025, July 30, 2025, August 7, 2025, August 13, 2025, and August 14, 2025, LPA did not observe any residents in need of care and not receiving assistance from facility care staff. Based on interviews conducted and observations, 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 was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents. Relevant party reported to the Department that resident (R3) was observed to be residing in the Assisted Living Unit (ALU) of the facility while participating in activities and spending most daytime hours in the Memory Care Unit (MCU) of the facility. A review of Title 22 regulations did not indicate any violations distinguishing care needs of residents in ALU settings in opposition to care needs of residents in MCU settings. Interviews with staff members S1, S2, S3, S4, S5, S6, and S7 indicated that they have never observed the facility retaining residents beyond a level of care they can provide, including prohibited health conditions. Interviews with residents R7 and R8 indicated that they have never witnessed residents residing at the facility who are in need of a level of care the facility cannot provide. LPA reviewed records for R3, including R3's Physician's Report (LIC 602A) dated July 10, 2024 and Resident Assessments dated October 13, 2023, April 3, 2024, July 12, 2024, December 12, 2024, January 1, 2025, and June 19, 2025, which did not indicate that R3 sustained any prohibited health conditions or required a level of care that the facility could not provide. Interview with R3's representative indicated that they had no concerns regarding the care provided at the facility and they feel care staff do a good job providing care to R3. 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 was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Aug 14, 2025 · control 59-AS-20250529100321

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 15, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication counts and records reviewed, the facility did not ensure that residents R1, R2, R3, and R4 were receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2025

Plan of correction: Facility had a office meeting with Community Care Licensing and will continue to implement plan that was established during meeting. In-service will be conducted with med-techs, Health Services Director, Memory Care Director, and Resident Care Coordinator. Facility will submit time of training and training agenda by POC due date of 8/15/2025.

Allegation investigated: Facility is not addressing resident sustaining falls

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Pouya Ansari, to deliver findings into the complaint allegation listed above. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Facility is not addressing resident sustaining falls ** Report continued on 9099-C ** Substantiated During visit conducted on May 6, 2025, LPA Angela Hood toured the facility, including resident (R1’s) apartment, and conducted an interview with R1. LPA observed R1’s walker was positioned next to bed with catheter bag hanging from walker to allow resident to get up and walk. LPA observed small rail at the head of R1’s bed to assist resident when getting up from bed. Interview with R1 indicated that they need a lot of help after breaking hip and are considered a fall risk due to vertigo. R1 indicated that they feel staff do not assist often and leave quickly to help other residents. LPA interviewed ED, who indicated that R1 had a fall and broke their hip on March 24, 2025. Additional interviews conducted by LPA Michael Hood did not indicate any concerns regarding how the facility addresses residents sustaining falls. LPA Michael Hood reviewed records maintained on cite for R1, including R1’s Resident Assessments and Charting Notes. LPA observed, according to R1’s Charting Notes, that R1 was either observed or reported falls on October 11, 2024, November 11, 2024, January 5, 2025, March 24, 2025, May 23, 2025, and June 3, 2025. LPA received Unusual Incident/Injury Reports (SIRs) for falls dated November 11, 2024, January 5, 2025, March 24, 2025, and June 3, 2025. SIR for November 11, 2024 indicates that R1 was sent to the hospital after sustaining a fall and necessary reporting was conducted. SIR for January 5, 2024 indicates that R1 was sent to the hospital after sustaining a fall and necessary reporting was conducted. SIR for March 24, 2025 indicates that R1 was sent to the hospital after sustaining a fall and necessary reporting was conducted. SIR for June 3, 2025 indicates that R1 was sent to the hospital after sustaining a fall and necessary reporting was conducted. LPA reviewed R1’s Resident Assessments dated April 15, 2025 and May 2, 2025. Neither assessment determined R1 as a fall risk. Charting Notes for R1 show that staff were monitoring R1 for falls starting April 25, 2025 upon R1’s return from the hospital. Charting Notes indicate that R1’s family was contacted on May 1, 2025 to add fall prevention to R1’s care plan and R1’s care plan was updated on May 20, 2025 to add fall prevention. LPA reviewed Resident Assessment for R1 dated May 20, 2025 and observed R1 to be determined as a fall risk. ** Report continued on 9099-C ** Charting Notes for October 11, 2024 states the following: “Resident paged at about 4am, told care staff [they] had a fall, however when Med Tech made more inquiries about how [they] fell, where, and if [they] hit [their] head, [R1] mentioned [they] hit [their] head on [their] bed, and [they] went on and on about how miserable [they were] feeling.” There is no other documentation for October 11, 2024 indicating what the facility did in response to R1 reporting a fall, whether they notified anyone, whether on cite nurse evaluated R1 for injuries, and whether emergency services were contacted. Facility could not provide any SIRs for R1 for the date of October 11, 2024 during investigation. Charting Notes for May 23, 2025 states the following: “RESIDENT HAD AN UNWITNESSED FALL BY THE DOOR. [R1] WAS CALLING OUT FOR HELPED. [They were] ON THE FLOOR BEHIND THE DOOR. [Their] WALKER WAS BY [their] BED. WE HELPED [R1] UP AND [they] WALKED WITH THE WALKER TO [their] BED, A LITTLE BUMP ON HEAD. PUT ICE ON IT BUT [R1] SAID ITS TOO COLD TO TAKE IT AWAY. CALLED [family] FROM [their] PHONE AND INFORMED [them] ABOUT IT. [They] ASKED IF [R1] IS OK TOLD [them] YES. [They] SAID OK THANK YOU FOR CALLING AND LETTING [them] KNOW.” There is no other documentation for May 23, 2024 indicating whether on cite nurse evaluated R1 for injuries and whether emergency services were contacted. Facility could not provide any SIRs for R1 for the date of May 23, 2024 during investigation. PIN 25-06-ASC states the following: “to ensure resident safety, licensees as a best practice should immediately call 9-1-1 if a resident is experiencing any of the following symptoms/conditions listed below: (…) Falls with suspected head injury.” Based on records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency are being cited on the attached 9099-D page. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents. During visit conducted on May 6, 2025, LPA Angela Hood toured the facility, including R1’s apartment, and conducted an interview with R1. LPA observed R1’s apartment to be clean and tidy. LPA did not observe any large stains on the floor or strong odors. Interview with R1 did not indicate any concerns with cleanliness of their apartment. R1 stated that they love living at the care home and would recommend the care home to anyone. LPA interviewed ED who stated that staff clean sheets, towels, and personal clothing once a week, as well as clean bathrooms and vacuum floors. ED stated that staff may clean apartment more often if resident soils themselves. ED stated that garbage is dumped more frequently (daily). ED stated that R1 eats in their room. ED stated that R1 has pulled out their catheter. ED stated that, a couple days after returning to the care home from the hospital, R1’s catheter had fallen out and leaked onto the floor. ED stated that carpet was cleaned with carpet extractor. ED stated that, after a second time R1’s catheter fell out, a work order was placed and completed to clean the carpet. LPA Michael Hood observed a work order to clean urine spill in R1’s apartment dated April 30, 2025. Interview with residents R2, R4, and R5, as well as staff members S2, S3, S4, and S5 indicated that they have never observed anywhere in the facility to be unclean or in disrepair. S2, S3, and S4 stated that housekeeping and maintenance do a good job at the facility. Interview with representative from Home Health agency assisting R1 with their catheter indicated that the nurses assisting R1 had no concerns regarding cleanliness of the facility. During visit conducted on May 21, 2025, LPA observed R1 and their apartment and observed R1’s apartment to be clean and sanitary. During visits conducted on May 20, 2025, May 21, 2025, July 30, 2025, August 6, 2025, and August 7, 2025 LPA Michael Hood observed areas toured at the care home to be clean and in good repair. Allegation: Facility staff are not providing adequate assistance with resident’s catheter Relevant party reported that facility staff were not providing adequate assistance with R1’s catheter. ** Report continued on 9099-C ** During visit conducted on May 6, 2025, LPA Angela Hood toured the facility, including R1’s apartment, and conducted an interview with R1. LPA observed R1’s catheter bag to be new and empty. LPA observed R1’s walker was positioned next to bed with catheter bag hanging from walker to allow resident to get up and walk. Interview with R1 indicated that they feel uncomfortable having a catheter. Interview with ED indicated that R1 returned to the facility after being hospitalized and had pulled their catheter out the first night back. ED stated that R1 had pulled out their catheter twice. ED stated that R1’s Home Health agency was caring for R1’s catheter, while facility staff monitored the situation prior to R1’s Home Health being established. ED stated that R1 was sent to the hospital on April 26, 2025 regarding R1 removing their catheter. Unusual Incident/Injury Report (SIR) dated April 26, 2025 regarding the incident indicated that R1 had no complaints of pain and R1 returned to the community with urinary catheter replaced. ED stated that facility caregivers were responsible for changing out the catheter bag while Home Health provided extra bags. ED stated that facility caregivers were responsible for cleaning the catheter insertion point. Interviews with S2, S3, and S4 indicated that they didn’t have any concerns regarding facility staff’s assistance with residents’ catheters. Interview with representative from Home Health agency assisting R1 with their catheter indicated that the nurses providing assistance to R1 regarding their catheter did not have any issues with the environment of the facility or neglect. Home Health records indicate that R1 started Home Health services on April 28, 2025. Allegation: Facility staff are not providing adequate food services to residents in care During visit conducted on May 6, 2025, LPA Angela Hood met with R1 and conducted an interview with R1. R1 indicated that food at the facility is “excellent” and they have no complaints about the food at the facility. R1 stated that they get plenty of food to eat. Interview with ED indicated that R1 eats specific things that the facility provides. Interview with R2, R4, and R5, as well as S2, S3, S4, and S5 indicated that they did not have any concerns regarding food services at the facility. R2, R3, R5, and staff member (S1) acknowledged that there is a "chef forum" in which residents can disclose their food preferences to the facility chef. ** Report continued on 9099-C ** LPA Michael Hood toured the kitchen on May 20, 2025 and August 6, 2025 and observed food at the facility to be of good quality. Allegation: Facility staff are not providing proper hygiene assistance to residents in care During visit conducted on May 6, 2025, LPA Angela Hood toured the facility, including R1’s apartment, and conducted an interview with R1. LPA observed R1 to be clean and their hygiene needs to be met. LPA did not observe any large stains on the floor or strong odors. R1 stated that there was one caregiver providing showers where the water was cold and the caregiver was a little rough handling R1, but they haven’t had a shower with the caregiver since their negative experience. R1 stated that facility staff are like family and are very kind. Interview with ED indicated that staff clean sheets, towels, and personal clothing once a week, as well as clean bathrooms and vacuum floors. ED stated that staff may clean apartment more often if resident soils themselves. ED stated that R1 requires assistance with showering. Interview with R2, R3, R4, and R5 indicated that they are treated well by facility staff and they feel that their care needs are being met at the facility. Interview with S2, S3, S4, and S5 indicated that they have no concerns regarding hygiene assistance provided to the residents in need at the care home. Interview with representative from Home Health agency assisting R1 with their catheter indicated that nurses assisting R1 did not have any concerns regarding hygiene assistance or incontinence care for R1. LPA Michael Hood reviewed records maintained on cite for R1, including R1’s Staff Assignments by Month by Unit, which indicated that R1 was receiving daily assistance with activities of daily living. Based on interviews conducted, observations, 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 was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Aug 7, 2025 · control 59-AS-20250429112340

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

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by: Based on records reviewed, the facility did not ensure to contact 9-1-1 after R1 sustained falls with potential head injuries on two (2) occasions, which poses an immediate health, safety, and/or personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Aug 7, 2025

Plan of correction: Facility will conduct an in-service with staff regarding 9-1-1 reporting protocols. Facility will submit information regarding in-service training, including date of training and materials, to LPA by POC due date of 8/8/2025.

Type of visit: Office

On June 19, 2025, a non-compliance conference was conducted. The purpose of this conference meeting was to address non-compliance at the facility after being issued 7 Type A citations and 23 substantiated complaint allegations since being licensed July 27, 2021. Present in the meeting was CCLD staff, including Regional Manager Alycia Rayner, Licensing Program Manager Lauren Crocker, Licensing Program Analyst Michael Hood, and facility staff, including the Administrator Pouya Ansari, Vice President of Operations Terry Ervin, Senior Vice President of Operations Scott Carlson, Vice President of Quality Assurance and Regulatory Affairs Sue McPherson, Regulatory Director of Quality Assurance Kevin Wrigley, Northern California Director of Health Services Melissa Malek, and Partner at Hanson Bridgett Law Firm Joel Goldman. The conference process was explained during this meeting. Issues discussed during this meeting were: · An overview of citations issued on August 29, 2023 · Repeat violations regarding medication errors - medication management The facility has stated that they will do the following to achieve continued and substantial compliance: · Enforce systems in place for quality assurance of medication management & observation of residents · Ensure staff competency following required training Facility was notified that the Department may increase monitoring at the facility and the completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager. Exit interview was conducted and a copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jun 19, 2025

Allegation investigated: Licensee is not ensuring that staff are adequately trained on emergency evacuation protocols.

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Pouya Ansari, to deliver findings for the complaint allegation listed above. During the investigation, LPA conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Licensee is not ensuring that staff are adequately trained on emergency evacuation protocols. Relevant party reported to the Department that the facility had a fire on February 1, 2025 and staff were not properly trained on emergency evacuation protocols to properly address resident evacuations during fire. ** Report continued on 9099-C ** Substantiated Interview with ED indicated that there was a small fire in the laundry room in the Memory Care Unit (MCU) on February 1, 2025 caused by a dryer in the laundry room. ED stated that staff were supposed to only evacuate residents in the MCU during fire on February 1, 2025, while some residents with oxygen were to shelter in place with care staff supervision. ED stated that fire department was contacted via the alarms and arrived promptly to address the fire. ED stated that the fire was put out when the sprinkler system was activated. LPA received an incident report from Sacramento Metropolitan Fire indicating that a fire took place on the premises February 1, 2025. Fire alarm activated at 5:56 AM and fire fighters arrived at the facility at 6:02 AM. Last unit was cleared at 7:29 AM. Incident type was "fires in structure other than building." Incident resulted in zero (0) injuries or deaths. Fire fighters reported light smoke condition in the hallway with occupants evacuating. Officer reported assisting with occupant evacuation on the second floor. Fire was contained to the laundry room in the clothes dryer and smoke was being exhausted to the exterior. Rooms 106-122 were uninhabitable due to smoke and/or water/smoke impacts. Engineer shut off and drained sprinkler system. Officer replaced the open sprinkler head and recharged the sprinkler system. Report indicated the origin of the fire to be the laundry room contained to a commercial clothes dryer due to a large lint trap. Interviews with staff members S1, S2, and S3 indicated that they do not feel adequately trained on emergency evacuation protocols. S1 stated that they were at the facility on February 1, 2025 during the fire and didn't feel properly trained on how to address a fire at the facility. S1 stated that they were not properly trained on getting wheelchair bound residents evacuated. S1 stated that the fire department was contacted when the fire alarms went off. S1 stated that they were already evacuating residents due to the smoke and got everyone out in 20 minutes at the most. S1 stated that more than half of the residents were evacuated when the fire department arrived. S1 stated that half the top floor was not evacuated, including room 237, and room 225 to room 231. S1 stated that no one had told staff not to evacuate the second floor. S1 stated that a few residents downstairs were not evacuated, including bed bound residents who needed hoyer lift assistance. S2 stated that they were at the facility during fire on February 1, 2025. S2 stated that they have worked at the facility for two (2) and a half years and has only participated in one quarterly drill. S2 stated that they were evacuating residents on the second floor and only 85 to 90 percent of the second floor was evacuated. S2 stated that they didn't feel prepared to handle the emergency. S3 indicated that they have never received Disaster and Emergency Plan training and have not participated in a quarterly drill. ** Report continued on 9099-C ** LPA reviewed facility's Plan of Operation maintained at Sacramento North Regional Office. LPA observed Operations Policy revised January 1, 2019 indicated the following: "Disaster and Emergency Plan...All staff will receive training on the Disaster and Emergency Plan upon hire and annually thereafter. The training will include staff responsibilities during an emergency or disaster." No objectives and content for Disaster and Emergency Plan training was indicated in Operations Policy. LPA observed training documentation for staff members S3, S4, S5, and S6. LPA observed that staff received "Fire Safety" training via Relias Learning upon hire and annually. LPA observed the course objectives for the Fire Safety training in Relias Learning, but could not verify if Fire Safety training met the requirements indicated in the Plan of Operation for Disaster and Emergency Plan training. LPA observed documentation for an annual review of the facility's Emergency and Disaster Plan conducted for the years of 2021, 2022, 2023, and 2024. LPA observed that documentation indicated that the Executive Director conducted the review of the plan with existing employees for the years of 2021 and 2022. Documentation did not include a list of the employees who participated in the review and was not documented in accordance with Title 22 regulations regarding personnel training. LPA observed that the documentation for the annual review of the Emergency and Disaster for 2023 and 2024 did not indicate that the plan was reviewed with existing employees. Based on interviews conducted 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 was conducted with ED. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, May 22, 2025 · control 59-AS-20250328120733

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Jun 27, 2025

87208 Plan of Operation (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. (...) This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure that there was adequate records ensuring staff were trained in Emergency and Disaster Plan in accordance with the facility's Plan of Operation, which poses a potential health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Facility will create a plan to address Emergency and Disaster Plan training which includes specifying objectives of training in Plan of Operation, documenting training in accordance with Title 22 personnel training, and ensuring all staff are actively participating in training. Plan will be submitted to LPA by POC due date.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 5/21/25 to conduct an annual continuation visit utilizing the inspection tool following the Required-1 Year Inspection conducted on 5/20/2025. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed three (3) apartments in the Assisted Living Unit, three (3) apartments in the Memory Care Unit, and three (3) 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 observed the perimeter of the care home to be free of clutter and debris. LPA ensured that delayed egress in Memory Care was operational. 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. Smoke detectors and carbon monoxide detectors are hard wired in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use. As a result of today's visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, May 21, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 5/20/25 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA reviewed five (5) resident files and four (4) staff files. LPA reviewed two (2) residents' medications and observed medications to be locked away and inaccessible to the residents. Facility has a current copy of certificate of liability insurance and LPA obtained a copy. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. LPA will return at a later time to conduct a tour of the premises, conduct interviews with staff and residents, and 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 20, 2025

Allegation investigated: Facility staff are not assisting resident with oxygen

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Pouya Ansari, to deliver findings into the complaint allegation listed above. During the course of the investigation, LPA toured the facility, conducted interviews, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Facility staff are not assisting resident with oxygen ** Report continued on 9099-C ** Unsubstantiated Relevant party reported that facility staff are not ensuring that resident (R1's) portable oxygen is charged and operable for when R1 is ambulating throughout the facility. LPA observed an After Visit Summary from an Emergency Room visit for R1 dated 10/21/2024 which states "please administer oxygen 2L by nasal cannula when ambulating" for R1. During visits conducted during the investigation, LPA observed R1 in their apartment wearing their nasal cannula to their concentrator. LPA observed nasal cannula tube to be long enough to allow R1 to ambulate throughout their apartment. LPA observed R1's portable oxygen plugged in and charged during visits. LPA interviewed R1 during multiple visits, who stated that they are doing well and have no concerns regarding the facility. LPA interviewed staff members S1, S2, and S3, who stated that they ensure that R1 is wearing the nasal cannula to their oxygen while ambulating in the common areas of the facility and ensure that R1's portable oxygen is charged or plugged in and operating while in the common areas of the facility. Based on interviews conducted, observations, 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 was conducted with ED. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jan 3, 2025 · control 59-AS-20241105152831

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Pouya Ansari, to follow-up regarding information obtained after previous inspection. Based on records reviewed by the Department, ED does not currently have an active Administrator certificate. A deficiencies is being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiency is listed on the attached 809-D page. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. ED's signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, May 21, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Jun 3, 2024

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. (...) This requirement is not met as evidenced by: Based on records reviewed, the facility did not ensure that Administrator had an active Administrator certificate, which poses an potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 21, 2024

Plan of correction: Facility will submit required paperwork to assign an individual with an active Administrator certificate as the facility's Administrator by POC due date of 6/03/2024.

Allegation investigated: Staff are not following resident's care plan

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Pouya Ansari, to deliver findings into the complaint allegation listed above. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: ** Report continued on 9099-C ** Unfounded During multiple visits conducted at the facility, LPA observed the facility to have four (4) hoyer lifts on cite and one (1) sit-to-stand lift on cite. LPA observed four (4) residents to be receiving assistance with a hoyer lift or sit-to-stand lift and reviewed their care plans to ensure that necessary care was documented. LPA observed staff schedule and observed a sufficient number of staff scheduled per shift. Interviews conducted with staff members S1, S2, S3, and S4 indicated that they have never witnessed residents in need of a hoyer lift not receive staff assistance with a hoyer lift, never witnessed residents being lifted by staff in an unsafe way, and never witnessed residents not receiving services in accordance to their care plan. Interviews conducted with residents R1, R2, R3, R4, and R5 indicated that their care needs are being met at the facility. R1, R2, R3, and R4 confirmed that they use a hoyer lift or a sit-to-stand lift and indicated that they have had no bad experiences receiving care with the lift and no issues with safety regarding the lift. Based on interviews conducted, observations, 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 was conducted with ED. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, May 10, 2024 · control 59-AS-20240429100901

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 5/10/24 to conduct an annual continuation visit utilizing the inspection tool following the Required-1 Year Inspection conducted on 5/9/2024. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed four (4) apartments in Assisted Living. LPA interviewed five (5) residents during inspection. As a result of today's visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, May 10, 2024

The state marks this report as 5 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 5/9/24 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed three (3) apartments in Memory Care and three (3) 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 114.8 degrees F. LPA observed the perimeter of the care home to be free of clutter and debris. LPA ensured that delayed egress in Memory Care was operational. 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. Smoke detectors and carbon monoxide detectors are hard wired in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medication to be locked away and inaccessible to the residents. LPA reviewed five (5) resident files and four (4) staff files. Facility has a current copy of certificate of liability insurance and LPA obtained a copy. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. LPA will return at a later time to conduct interviews with residents and 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 9, 2024

The state marks this report as 5 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff are not meeting a resident's oxygen needs while in care

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Pouya Ansari, to deliver findings into the complaint allegation listed above. During the investigation, the Department conducted inspections and interviews, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Interviews with multiple relevant parties indicated that resident (R1) is supposed to be wearing and using their oxygen whenever they are ambulating outside of their apartment. ** Report continued on 9099-C ** Substantiated Interview with staff (S1) indicated that R1 is not really using their oxygen and only uses it if staff observe R1 is out of breath. Interview with staff (S3) indicated that R1 uses oxygen only when they walk around the facility, but most of the time they don't use it and don't need it. Interview with staff (S4) indicated that they were told that R1 didn't need their oxygen and R1 only uses their oxygen sporadically when they are walking. LPA reviewed R1's Physician's Report for RCFE (LIC 602A) dated 7/18/2023, which indicates that R1 has a diagnosis of Chronic Respiratory Failure and Hypoxia as of 5/2022. LPA reviewed Doctor's Order Sheet for R1's oxygen dated 10/20/2023, which states "PRN use of Oxygen when active or ambulating. Staff is to help patient with use of oxygen when needed." During visit conducted on 1/10/2024, LPA observed R1 in the activity room without their oxygen with them. LPA observed R1's oxygen in their apartment while R1 was in the activity room and not in their apartment. Based on interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegation is 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. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents. During visit conducted on 1/10/2024, LPA tested R1's call button in bathroom and observed staff respond to call in a timely manner. Interview with ED and multiple relevant parties indicated that R1 does not use and misplaces call button. Interview with ED indicated that R1 is no longer using a call button at the time of this report. No interviews conducted during investigation indicated any concerns regarding care and supervision for R1. Interviews with staff indicated that 2 hour rounds are completed for all residents in the Memory Care Unit of the facility to provide care and supervision to the residents in care. Interview conducted with R1 indicated that they had no concerns regarding the facility, they have everything they need, they are treated well by staff, they have plenty to do, and their care needs are being met in the timely manner. LPA observed an activities calendar for the Memory Care Unit of the facility and observed activities taking place throughout the facility during multiple visits. During multiple visits, LPA observed R1 participating in activities. Interviews with staff indicated that they have observed R1 actively participating in activities at the facility. Interview with staff and relevant party indicated that R1 has a hired companion every Monday, Wednesday, and Friday who ensures that R1 is participating in activities. Based on interviews conducted, observations, 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 was conducted with ED. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jan 31, 2024 · control 59-AS-20230915101913

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87611(e) · Plan of correction due date: Feb 1, 2024

87611 General Requirements for Allowable Health Conditions (e) In addition to Sections 87465(a) and 87464(d) the licensee shall ensure that the resident is cared for in accordance with the physician's orders and that the resident's medical needs are met. This requirement is not met as evidenced by: Based on interviews conducted, observations, and records reviewed, facility did not ensure that PRN order for R1's oxygen was followeed, which poses an immediate health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jan 31, 2024

Plan of correction: Facility will ensure that R1 has their oxygen when active or ambulating in the facility. A training regarding use of oxygen will be completed for staff. ED will complete a statement of understanding regarding 87611. Facility will submit statement of understanding, along with date and materials for staff training, to LPA by POC due date of 2/1/2024.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Pouya Ansari, to obtain a signature relative to amending a report for an inspection conducted on 10/18/2023. Signature was obtained for amended document during visit. Exit interview was conducted with ED. A copy of this report and was provided. ED's signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Oct 20, 2023

Allegation investigated: Staff did not give resident's medication as prescribed Facility is not providing PPE to staff who are in direct contact with residents with a contagious disease

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Pouya Ansari, to deliver findings into the complaint allegations listed above. During the investigation, LPA conducted interviews, conducted a medication count, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: ** Report continued on 9099-C ** Substantiated During a visit conducted on 10/05/2023, LPA conducted a medication count for resident R1, comparing the resident’s Centrally Stored Medication Form (CSM) with medications centrally stored for the resident. LPA observed one (1) medication for R1 that was off count in relation to what was documented. Medication that was off count was over the amount documented. There were no documented refusals for R1’s medication when reviewing R1's medication Admin History. LPA reviewed Shift Reports and observed that it was noted under NOC shift notes for 9/22/2023 that new medications for R1 were delivered and ready to use at 4:00 AM on 9/22/2023 despite R1's medication not being documented as given until 9/23/2023. Interviews conducted indicated that the documented date for when medications were received was incorrect. On 10/06/2023, ED informed LPA that they began conducting an internal investigation and discovered that bubble pack for R1's medication had tape on the back of the bubble pack, indicating that pills had been placed in the pack after the seal had been broken. ED also discovered a bottle of the same medication for resident (R2) that was supposed to be destroyed underneath a staff member's (S2's) desk with tin foil inside the bottle. ED stated that there was no documentation indicating that R2's medication had been destroyed or removed from the medication room. During a visit conducted on 10/05/2023, LPA conducted a tour of the facility to inspect facility's Personal Protective Equipment (PPE). LPA observed facility had a sufficient supply of N-95 respirators, surgical masks, gloves, face shields, gowns, and hand sanitizer. LPA observed one (1) resident on isolation due to COVID-19 exposure and COVID-19 symptoms (resident refused to test). LPA observed PPE cart outside of resident's apartment and observed cart did not have N-95 respirators. LPA also did not observe PPE instructions posted outside of resident's apartment. LPA interviewed representative from Sacramento County Public Health. They stated that they still advise staff working at long-term care facilities to use full PPE when caring for residents who are in isolation due to COVID-19 per PIN 23-13-ASC. PIN 23-13-ASC states the following: "Important! Facility staff must wear the appropriate PPE (i.e., N95 respirator, and gloves) pursuant to facility specific regulations. Licensees are encouraged to have signage in the facility on proper PPE donning and doffing." ** Report continued on 9099-C ** Based on interviews conducted, a medication count, observation, 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. Two civil penalties in the amount of $250 are assessed for the date of 10/18/2023 for repeat violations within 12 months of a prior violation of a statutory or regulatory provision designated by the same combination of letters or numerals per Health and Safety Code §1548. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. ED's signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Oct 18, 2023 · control 59-AS-20230929105355

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 19, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication counts and records reviewed, the facility did not ensure that resident R1 was receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 18, 2023

Plan of correction: Facility will complete an inservice with staff regarding medication administration. Facility will also continue bi-weekly medication audits. Facility will submit to LPA information regarding in-service training and medication audit, including time and date of in-service and training material, by POC due date. A civil penalty of $250 is assessed for a repeated violation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 2, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observation, facility did not ensure that staff were wearing full PPE when working with residents on isolation for COVID-19, which poses a potential health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Oct 18, 2023

Plan of correction: Facility will complete an inservice with staff on proper donning and doffing of PPE. Facility will submit training documents to LPA by POC due date. A civil penalty of $250 is assessed for a repeated violation.