Oakmont of Lodi

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Jason arrived unannounced to this facility to conduct a case management visit. LPA Lund was greeted by Facility Designated Administrator (FDA), Andrea Armstrong and explained the purpose of the visit. The purpose of this case management visit was to conduct a quarterly visit as outlined from the Non Compliance Conference held on 03/25/2024 and the requirement to have increased monitoring at that time. The focus of this quarterly visit was to review the following items that were initially brought forth on 03/25/2024: I. Medication Errors II. Staffing Concerns III. Reporting Requirements IV. Medication Training V. Facility Polices Regarding: Assessments, Monitoring of Residents, Change in Condition, Medication Errors. During today's visit, LPA Lund conducted a tour of the Assisted Living, kitchen, outside areas, and memory care unit. It was learned during the course of this tour that this facility has 3 caregivers, 1 medication technician, and 1 activity director in each memory care and assisted living areas. In addition, the assisted living units have an additional activities aid and facility driver. LPA Lund reviewed the Medication rooms in both the Assisted Living and Memory Care areas. Policies and procedures involving the handling, dispensing, and documentation of the resident medications were discussed with the present medication technician at this time.A review of the facility Medication Administration Record was conducted. It was observed that this facility currently employed an electronic Medication Administration Record (E-MAR) system as well as documenting on forms and documents as well. A review of the facility narcotics policies and procedures was conducted. In addition, a review of the Controlled Medication Administration Record for the resident narcotics was conducted. It was observed by this LPA that on PRN and daily logs have been completed and dated by the Medication Technician as of this date, 7/29/2026. A review of the assigned tasks and duties for caregivers to complete for all three shifts for memory care and assisted living (AM, PM, NOC or referred to as Day, Evening, and Night) was reviewed for proper documentation and notation at this time. All other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. LPA Lund conducted a test of the facilities delayed egress system. A facility log book also was reviewed which documented the facilities daily check of the locked doors. The following documentation was requested to be submitted to this LPA Lund by 08/03/2026 by 5:00pm -Last medication audit conducted by the partnering pharmacy -Staffing schedule for the June-July 2026. -Medication Training past 3 months has been sent via email to Jason.lund@dss.ca.gov for review -Facility Polices Regarding: Assessments, Monitoring of Residents, Change in Condition, Medication Errors - any in services related to the above over the past 3 months to be sent via email to Jason.lund@dss.ca.gov for review No deficiencies were observed and a copy was given to the facility designated Administrator Andrea Armstrong at this time. Exit interview.the state’s words, verbatim · CDSS document, Jul 30, 2026

Allegation investigated: Facility did not safeguard resident's personal belongings

Unannounced complaint visit made out to this facility on 04/27/2026 by Licensing Program Analyst (LPA) Areille Pascua. This LPA was met by the facility designated Administrator, Andrea Armstrong, who was briefly interviewed at this time. Current census was 86 residents. This visit was conducted in order to deliver the findings of this investigation to this facility, and its representative, at this time. Based on a review of the forms and documents that were gathered during the course of this investigation, it was learned that R1 moved into this facility back in the early part of 2023. It was learned that R1 was already diagnosed as being non ambulatory but resided originally in the Assisted Living portion of this facility at that time. Substantiated It was learned that R1 eventually was diagnosed with dementia and was moved over to the memory care portion, Traditions, of this facility at a later date. This diagnosis was reflected on the LIC 602 that was completed on 02/20/2024. Based on a review of the forms and documents that were gathered during the course of this investigation, it was learned that this resident, R1, had already lost their dentures from a prior incident that took place earlier in their placement to this facility. It was learned that there was a second incident that took place where the resident was unable to recall where their dentures were last seen and their family and responsible party were made responsible in replacing them again. Based on interviews conducted during the course of this investigation, it was learned that the staff were tasked with making sure that proper oral hygiene and care were to be maintained on a daily basis for R1. This task was outlined and implemented on the daily tasks assignment for R1. After the completion of each assigned task, facility personnel would then initial to note that the task had been completed. It was learned that facility staff were unaware as to how the dentures for R1 would have gone missing and did not have a plausible reason at this time. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated Administrator at this time. Exit Interview Based on a review of the forms and documents that were gathered during the course of this investigation, it was learned that the new pain medication, Hydrocodone, was prescribed and filled on 11/09/2025 when it was dropped off to this facility. This medication was only a PRN and was not to be dispensed on a daily basis but only when the resident, R1, expressed pain and discomfort. It was learned that from 11/09/2025 to when the resident got their staples removed from their back surgery on 11/19/2025, this medication was dispensed a total of 11 times to the resident. Each time this medication was dispensed it was noted and entered into the facility Medication Administration Record (MAR) and charting notes as well. Based on a review of the forms and documents that were gathered during the course of this investigation, it was learned that there were daily tasks assigned to the facility staff which were to be performed and completed relevant to the care and supervision of R1 on a daily basis. These tasks ranged from toileting, dressing, and assistance with Activities of Daily Living (ADLs). It was observed that these tasks were completed and signed off after their completion by the staff person on duty. These duties spanned over 24 hours for each day and were broken down for each 8 hour shift as well. It was observed that the tasks were clearly signed off by the assigned facility personnel without any missing initials at this time. The months that were reviewed were from the beginning of August 2025 until the end of November 2025. Based on interviews conducted during the course of this investigation, it was learned that the Memory Care Director had oversight for the daily tasks assigned to the facility personnel and audited these logs on a weekly to a monthly basis to make sure that they were complete and not missing any duties at any given time. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Apr 27, 2026 · control 27-AS-20251211142748

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: May 11, 2026

(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This is not met as evidenced by: Based on interview and record review, the licensee did not ensure that they took the appropriate measures to safeguard the resident's dentures during their admission at the facility. This poses a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Apr 27, 2026

Plan of correction: The facility shall provide this LPA a statement of correction highlighting policies and procedures regarding the safeguarding of resident's property including but not limited to cash resources, personal property and valuables.

Allegation investigated: Staff did not provide adequate supervision to resident in care resulting in the resident leaving the facility unassisted Facility staff charged fees to the resident's authorized representative for services not listed in the admission agreement

Unannounced complaint visit made out to this facility on 03/30/2026 by Licensing Program Analyst (LPA) Arielle Pascua who was met by the facility designated Administrator, Andrea Armstrong, who was briefly interviewed at this time. Current census was 86 residents. The purpose of this visit was to inform this facility, and its designated representative, that the investigation had been completed and present the findings at this time. Based on interviews conducted, it was learned that R1 had eloped from this facility on 12/02/2025 during the early morning hours. It was learned that R1 had removed the window screen from R1’s bedroom window and climbed out. It was learned that R1 was diagnosed with dementia and was placed in the memory care unit, Traditions, at this facility. This memory care unit was equipped with delayed egress and alarms on all exits including the windows in the residents’ bedrooms designed to notify facility staff if any exits were used by any residents attempting to leave the premises. Substantiated Based on an interview with the facility designated Administrator, Andrea Armstrong, she admitted that the alarm for the window did not activate when R1 kicked out the window screen like it was designed to do which allowed R1 to climb out of R1’s bedroom window on 12/02/2025. It was learned that there were sensors placed on the windows and the screens so that if any of them were triggered then the system would have activated and facility personnel would have gotten the alerts. It was learned that if this alarm had triggered like it was designed to do then the system would have notified the facility staff to respond and would have possibly prevented the elopement of R1. It was learned that this facility did not have a definite timeline of when R1 eloped from this facility and had to involve local law enforcement, facility staff, and family/friends before R1 was found and brought back to this facility. It was learned that R1 had been gone from this facility for over 8 hours before she was returned safely back to this facility. It was learned that a similar incident of elopement for R1 took place on 11/29/2025 where R1 was able to exit the memory care unit and was later found in the Assisted Living portion of this facility. It was unknown to the facility staff and responsible parties for R1 as to how R1 was able to leave the secured perimeter of the memory care unit when it was equipped with a keypad before exiting and how the alarms were not triggered at that time. Based on a review of the forms and documents gathered during this investigation, it was learned that R1 moved into this facility on 10/31/2025 and had an initial assessment performed by this facility on 11/07/2025. A review of the Individualized Service Plan was conducted for R1 at this time. It was learned that a second assessment was conducted and completed on 12/05/2025 after the elopement incident which took place on 12/02/2025. It was observed that there weren’t any major changes noted on the updated assessment except for language addressing the risk for elopement and the staff’s responsibility to perform checks on R1 to redirect/reorient R1 when it was observed that R1 was gravitating towards facility exits. It was learned that all other areas regarding behaviors, Activities of Daily Living (ADLs), and Special Medical Needs were unchanged at this time. It was learned that R1 did not exhibit any behaviors which were a threat to R1 nor a threat to any other residents in care. Based on a review of the forms and documents gathered during this investigation, it was learned that One on One Supervision for Emergency Situations was an additional item and service that was elected by the resident, and their responsible parties, upon admission to this facility. It was learned that this item and service was not elected upon admission for R1. It was learned that this One-on-One service was implemented by this facility after the elopement incident for R1. It was learned that the One-on-One Care or Supervision could only be implemented if a resident was deemed to be a danger to themselves or others. Based on the updated assessment completed on 12/05/2025 R1 was never deemed to be a threat to themself or to others. As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Apr 27, 2026 · control 27-AS-20251204140501

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Apr 28, 2026

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This is not met as evidenced by: Based on interviews and record review. The Licensee did not ensure adequate supervision of residents in care. R1 was able to exit from their bedroom. This poses an immediate health and safety risk to the R1 in care.the state’s words, verbatim · CDSS document, Apr 27, 2026

Plan of correction: An immediate civil penalty of $500 was issued for violation of this Section. The facility administrator stated that elopement training was conducted in December 2025. A statement of correction and acknowledgement along with documented proof of scheduled training topics, dates, and times will be completed and submitted into CCL by the due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.957(a) · Plan of correction due date: May 11, 2026

(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. This is not met as evidenced by: Based on interview and record review, the licensee did not ensure that the resident's responsible representive was provided a notice of a rate increase based on their level of care. This poses a potential health, safety, and personal rigths risks to persons in care.the state’s words, verbatim · CDSS document, Apr 27, 2026

Plan of correction: The facility shall provide this LPA a statement of correction highlighting the facilities policies and procedures regarding rate increases and admission policies by POC date.

Allegation investigated: Staff do not ensure that resident is administered medication(s) according to physician's instructions. Facility did not provide care and supervision to resident.

Unannounced complaint visit made out to this facility on 04/27/2026 by Licensing Program Analyst (LPA) Areille Pascua. This LPA was met by the facility designated Administrator, Andrea Armstrong, who was briefly interviewed at this time. Current census was 86 residents. This visit was conducted in order to deliver the findings of this investigation to this facility, and its representative, at this time. Based on a review of the forms and documents that were gathered during the course of this investigation, it was learned that R1 moved into this facility back in the early part of 2023. It was learned that R1 was already diagnosed as being non ambulatory but resided originally in the Assisted Living portion of this facility at that time. The resident was already diagnosed and with back pain and constipation upon admission to this facility. It was learned that R1 eventually was diagnosed with dementia and was moved over to the memory care portion, Traditions, of this facility at a later date. This diagnosis was reflected on the LIC 602 that was completed on 02/20/2024. Unsubstantiated It was learned that R1 underwent back surgery on 11/05/2025 and returned to this facility on 11/07/2025. The resident, R1, was originally prescribed and taking their pain medications which were Pregablin and Tylenol at that time. It was learned that on 11/09/2025 a family member for R1 dropped off a new PRN medication, Hydrocodone, for pain management and provided a prescription and order for that medication at that time. However, this facility did not dispense the medication to the resident since there was not a signed order from the responsible licensed medical professional. This matter was later resolved that same day when the facility nurse contacted the pharmacy and discovered that this particular pharmacy had their licensed medical professionals digitally sign all of their orders. Since this order was completed electronically by the licensed medical professional there would not have been a signed paper copy to accompany the order at that time. The medication, Hydrocodone, was then administered to the resident, R1, as needed when R1 complained of any pain or discomfort. Based on a review of the forms and documents that were gathered during the course of this investigation, it was learned that the new pain medication, Hydrocodone, was prescribed and filled on 11/09/2025 when it was dropped off to this facility. This medication was only a PRN and was not to be dispensed on a daily basis but only when the resident, R1, expressed pain and discomfort. It was learned that from 11/09/2025 to when the resident got their staples removed from their back surgery on 11/19/2025, this medication was dispensed a total of 11 times to the resident. Each time this medication was dispensed it was noted and entered into the facility Medication Administration Record (MAR) and charting notes as well. It was learned that the daily tasks assigned to the facility staff were completed and signed off after the completion of each shift for care and supervision to the R1. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Apr 27, 2026 · control 27-AS-20251121113746

Type of visit: Case Management - Legal/Non-compliance

On 04/27/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA Pascua was greeted by Facility Designated Administrator (FDA), Andrea Armstrong and explained the purpose of the visit. The purpose of this case management visit was to conduct a quarterly visit as outlined from the Non Compliance Conference held on 03/25/2024 and the requirement to have increased monitoring at that time. The focus of this quarterly visit was to review the following items that were initially brought forth on 03/25/2024: Medication Errors Staffing Concerns Reporting Requirements Medication Training Facility Polices Regarding: Assessments, Monitoring of Residents, Change in Condition, Medication Errors. During today's visit, LPA Pascua conducted a tour of the Assisted Living, kitchen, outside areas, and memory care unit. It was learned during the course of this tour that this facility has 3 caregivers, 1 medication technician, and 1 activity director in each memory care and assisted living areas. In addition, the assisted living units have an additional activities aid and facility driver. LPA Pascua reviewed the Medication rooms in both the Assisted Living and Memory Care areas. Policies and procedures involving the handling, dispensing, and documentation of the resident medications were discussed with the present medication technician at this time. A review of the facility Medication Administration Record was conducted. It was observed that this facility currently employed an electronic Medication Administration Record (E-MAR) system as well as documenting on forms and documents as well. A review of the facility narcotics policies and procedures was conducted. In addition, a review of the Controlled Medication Administration Record for the resident narcotics was conducted. It was observed by this LPA that on PRN and daily logs have been completed and dated by the Medication Technician as of this date, 04/27/2026. In addition, medication has been logged and accounted for during medication pass at 1:12pm. A review of the assigned tasks and duties for caregivers to complete for all three shifts for memory care and assisted living(AM, PM, NOC or referred to as Day, Evening, and Night) was reviewed for proper documentation and notation at this time. It was observed that the facility staff did not properly fill out and initial into this binder when the assigned tasks had been completed for book #1 and Book#2. Book #1 did not have initials in this binder for 04/15 NOC shift, 04/20 AM shift, and 04/21 NOC shift. Book #2 did not have initials for 04/15 PM shift and 04/21 NOC Shift. A review of the memory care logs were conducted. In addition, the Staff Assignments by Month by Responsible Party/Resident Name for the month of April 2026 was reviewed by this LPA. It was observed that entries for R1 had not been completed logging bowel movements for 04/23, NOC and PM shift, 04/25 AM shift, and 04/26 for NOC shift. All other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. It was learned that the facility has implemented Safely You monitoring in all memory care units. LPA Pascua conducted a test of the facilities delayed egress system. A facility log book also was reviewed which documented the facilities daily check of the locked doors. The following documentation was requested to be submitted to this LPA by 05/01/2026 by 5:00pm -Last medication audit conducted by the partnering pharmacy -Staffing schedule for the March-April 2026. -Medication Training past 3 months has been sent via email to arielle.pascua@dss.ca.gov for review -Facility Polices Regarding: Assessments, Monitoring of Residents, Change in Condition, Medication Errors - any in services related to the above over the past 3 months to be sent via email to arielle.pascua@dss.ca.gov for review The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal Rights were printed and a copy was given to the facility designated Administrator Andrea Armstrong at this time. Exit interview.the state’s words, verbatim · CDSS document, Apr 27, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.312(b) · Plan of correction due date: May 11, 2026

(b) Assistance with instrumental activities of daily living in the combinations which meet the needs of residents. This is not met as evidenced by: Based on record review, The licensee did not ensure that the facility staff completed and initialed the logs for assisgned tasks and duties and monthly assisgnments were completed. This poses a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Apr 27, 2026

Plan of correction: The facility shall conduct training regarding the following Section for no less than an hour in duration. A statement of correction indicating how often the facility will audit the assigned tasks and duties book and acknowledgement along with documented proof of scheduled training topics, dates, and times will be completed and submitted into CCL by the due date.

Allegation investigated: Staff verbally abused and/or yelled at a resident while in care. Staff locked resident in room. Staff confiscated resident's personal belongings. Staff handled resident in a rough manner.

Unannounced complaint visit made out to this facility on 11/25/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Andrea Armstrong, who was briefly interviewed at this time. Current census was 91 residents. The purpose of this visit was to inform this facility, and it's representative, about the findings of this investigation in relation to the above allegations. Based on a review of the forms and documents obtained during this investigation, it was learned that the above allegations took place at this facility in the year 2022. It was learned that the facility resident(s) who were involved were no longer present and this LPA was unable to determine when and where they had been relocated to at the time of this complaint investigation. Based on a review of the forms and documents obtained during this investigation, it was learned that the facility staff who were involved in the above allegations were also no longer employed or present in the facility at this time. Unfounded Based on interviews conducted during this investigation, it was learned that the current Administrative team was not employed or present during the events surrounding the allegations to this complaint. This LPA was unable to interview the facility resident(s) involved nor was this LPA able to interview the facility staff persons alleged to be present and directly involved in these events at this time. This agency has investigated the complaint allegation(s). This agency has found that the complaint was UNFOUNDED, meaning that the allegation(s) were false, could not have happened and/or was without a reasonable basis. This agency has therefore dismissed the complaint. There were no deficiencies observed or cited during today’s complaint visit. Exit Interviewthe state’s words, verbatim · CDSS document, Nov 25, 2025 · control 27-AS-20251001112133

Type of visit: POC

Unannounced Plan of Correction visit made out to this facility on 11/25/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Andrea Armstrong. A brief interview was conducted with the facility designated Administrator at this time. Current census was 91 residents. The purpose of this visit was to follow up on the deficiencies that were cited from a prior annual visit conducted on 11/17/2025. This visit was to follow up on the Plan of Correction that was due. The following deficiency was observed and cited on 11/17/2025: In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. Plan of Correction clearance letter was printed and a copy was provided to the facility designated Administrator at this time. There were no further deficiencies observed or cited during today's Plan of Correction visit. Exit Interviewthe state’s words, verbatim · CDSS document, Nov 25, 2025

Type of visit: Required - 1 Year

Unannounced annual visit made out to this facility on 11/17/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Andrea Armstrong, who was briefly interviewed at this time. Current census was 91 residents. It was learned that there were (9) residents under the care of hospice at this time while (10) other residents were receiving services through home health as well. This facility does have a hospice waiver approved for (15) residents and fire cleared for bedridden and dementia care for residents at any given time. A tour of this facility was conducted. Administrator certificate was observed to be present for facility designated Administrator Andrea Armstrong at this time. Kitchen area was toured. Cabinets and drawers were reviewed. Food preparation stations, dishwashing station, and other areas intended for meal preps were toured. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe additional food storage units which were present and functional at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication rooms, located on each floor, were reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications were discussed with the facility designated medication technicians at this time. The medication carts were observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restroom was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. It was learned that there were several different floor plans for residents on the Assisted Living portion of this facility. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Linen closet, located in the facility laundry area, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time. A tour of the Memory Care unit was conducted. Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 04/25/2025 by the local fire extinguisher company, Alpha Fire Control, and in compliance at this time. First aid kits were observed to be present and contained all of the required components at this time. Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gates, and exits was conducted. A review of (10) facility resident files was conducted. A review of (10) facility personnel files was conducted. The following forms and documents were requested to be updated and submitted into CCL: LIC 308 LIC 400 LIC 500 LIC 610 The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code. Appeal Rights were printed and a copy was given to the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Nov 17, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Charlie Yang arrived on 10/23/2025 for an unannounced inspection to follow up on a case management visit in which deficiencies were cited related to injuries sustained by a resident in care. LPA Charlie Yang met with the facility designated Administrator Andrea Armstrong and explained the reason for the visit. On May 18, 2023, the Department conducted a case management visit and issued citations due to the facility not ensuring sufficient provisions were in place to aid in fall prevention of a resident (R1) after R1 sustained multiple falls over a four month period. The licensee was cited for violating California Code of Regulations (CCR) section 87405(h)(5) Administrator Qualifications and Duties and CCR section 87211(a)(D) Reporting Requirements. Today, the Department also issued a citation for CCR section 87464(d) Basic Services for not meeting R1’s needs after R1 was accepted for care. At the time of the visit on May 18, 2023, the issuance of a civil penalty was still being determined, and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code section 1569.49. 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 "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 information gathered through file review and documentation, the licensee did not appropriately address multiple fall episodes of R1 which led to R1 sustaining a right forehead contusion with findings of a subdural hemorrhage, after a fall episode on September 28, 2022, and R1 seeking medical intervention related to a hip contusion on September 13, 2022. Today, 10/23/2025, the Department will be issuing a Civil Penalty per Health and Safety Code section 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of ten thousand dollars ($10,000). An exit interview was conducted, and a copy of this report was given to the facility designated Administrator Andrea Armstrong. Appeal Rights provided. The facility designated Administrator, Andrea Armstrong's, signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Oct 23, 2025

Type of visit: POC

Unannounced Plan of Correction visit made out to this facility on 10/10/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated representative, Gale Schmidt (Business Office Director). A brief interview was conducted with the facility designated representative at this time. Current census was 87 residents.. The purpose of this visit was to follow up on the deficiencies that were cited from a prior complaint conducted on 09/25/2025. This visit was to follow up on the Plan of Correction that was due. The following deficiencies were observed and cited on 09/25/2025: A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self administered medications as needed: Plan of Correction clearance letter was printed and a copy was provided to the facility designated Administrator at this time. There were no further deficiencies observed or cited during today's Plan of Correction visit. Exit Interviewthe state’s words, verbatim · CDSS document, Oct 10, 2025

Allegation investigated: Staff do not ensure that resident's showering needs are met Facility is malodorous Staff do not ensure resident's toileting needs are being met Staff do not safeguard resident's belongings Staff do not respond to resident's calls for assistance

Unannounced complaint visit made out to this facility on 09/25/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Andrea Armstrong, who was briefly interviewed at this time. Current census was 84 residents. The purpose of this visit was to finalize this complaint and present the findings of this investigation to this facility, and it's representative, at this time. Based on a review of the facility Staff Assignments by Month for Staff and assigned Resident, it was observed that the tasks for assisting with showers/baths were properly completed and initialed by the assigned staff at this time. A review of this report was conducted for the months of June, July, August, and September 2025. Based on a review of the facility Staff Assignments by Month for Staff and assigned Resident, it was observed that the tasks for assisting with toileting needs were properly completed and initialed by the assigned staff at this time. A review of this report was conducted for the months of June, July, August, and September 2025. Unsubstantiated explanation or reasons at that time. Based on a review of the eMAR system utilized by this facility at this time, the section where notes and information would be entered if the medications were missed, refused, or not given did not have any information entered at this time. Based on interviews conducted during the course of this investigation, it was learned that if a date where the required initial and notes were not present in the eMar system then it would be considered that the medication was not properly dispensed to the resident at that time and missed for that timeframe. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. A civil penalty in the amount of $1000 was issued on the following LIC 421IM to this facility, and it's representative, at this time. Appeal rights were printed and a copy was left with the facility designated Administrator at this time. Exit Interview Based on a tour of the memory care unit, Traditions, it was observed that there were not any foul or bad odors detected at the time of this facility tour. A sample review of the facility resident bedrooms, as well as the resident restrooms, was conducted. Based on this review, there were not any foul or bad odors detected at the time of this facility tour. Based on a review of the facility theft and loss policies and procedures, it was observed that steps were put into place to address any incidents of loss by the residents and the facility's response in addressing these incidents. It was observed that an inventory sheet was also completed, if accepted by the resident and their responsible party on the Admissions Agreement, to inventory all personal belongings upon admission to this facility. This document was also updated, as necessary, in order to safeguard the resident and their belongings. This document also protected the facility in the cases of false allegations of theft or loss suffered by the facility resident. This facility was observed to have completed the required inventory log sheets for the residents in care at this time. Based on a review of the facility call log system, which was used by the facility residents to signal for help or assistance, it was learned that the response time for facility care staff to receive, respond, and reset the call for assistance was between 5-10 minutes. It was observed that there were incidents that were recorded outside of this timeframe but were reviewed on a case by case basis taking into account the time of day, staffing, and nature of the activation for service. It was observed that the response to the calls for service by the facility residents were being met for the 5-10 minute requirement at this time. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred. There were no deficiencies observed or cited at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Sep 25, 2025 · control 27-AS-20250825094456

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 26, 2025

Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: Based on a review of the facility medication administration record (MAR) and Controlled Medication Administration Record, it was observed that required initials/notes for prescribed medications were missing indicating that they were not properly dispensed which poses/posed an immediate risk to the health, safety, and personal rights of the residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: The facility designated Administrator stated that an audit of the facility medication administration records will be conducted for both the Assisted Living and Memory Care (Traditions) components. Training, for no less than (1) hour in duration, will be conducted on the topic of proper handling, dispensing, and documentation of all facility resident medications. A statement of correction, along with proof of updated medication training, will be completed and submitted into CCL by the due date. Proof of training will include name of trainer, training topic(s), and list of attendees.

Allegation investigated: Staff do not ensure PRN medication is used as prescribed for resident in care Licensee does not ensure staff is capable of performing job duties

Unannounced complaint visit made out to this facility on 09/25/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Andrea Armstrong, who was briefly interviewed at this time. Current census was 84 residents. The purpose of this visit was to finalize this complaint and present the findings of this investigation to this facility, and it's representative, at this time. Based on a review of the facility policies and procedures for staff handling, dispensing, and documentation of the resident PRN medications, as well as the e-Mar system used at this time, it was observed that the PRN medications were dispensed and documented as required. It was observed that all PRN medications dispensed to the residents were entered into the e-Mar system with the corresponding notes displayed at the end of this report under the section of Pass Notes. It was observed that all PRN medications dispensed were documented for the date, time, and reason for giving it unto the resident at that time. Unsubstantiated dates of 06/02/2025 and 08/02/2025 were missing without explanation or reasons at that time. Based on a review of the eMAR system utilized by this facility at this time, the section where notes and information would be entered if the medications were missed, refused, or not given did not have any information entered at this time. Based on interviews conducted during the course of this investigation, it was learned that if a date where the required initial and notes were not present in the eMar system then it would be considered that the medication was not properly dispensed to the resident at that time and missed for that time frame. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated Administrator at this time. Exit Interview Based on a review of the facility policies and procedures for facility personnel for all ranges of assigned tasks. duties, and classifications, it was observed that each classification came with it's own unique set of skills and requirements. It was observed that these classifications ranged from the following: Wait Staff Care Staff Medication Technicians Housekeepers Kitchen staff Activities staff It was observed that all of these classifications had their own training requirements in order for these assigned staff to be able to perform and conduct their assigned tasks and duties. A review of the facility personnel records revealed that annual training was completed for all staff providing care and supervision to the residents in care. In addition, additional training sessions were conducted for medication management, personal rights, and reporting requirements. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred. There were no deficiencies observed or cited at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Sep 25, 2025 · control 27-AS-20250828084237

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 26, 2025

Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: Based on a review of the facility medication administration record (MAR) and Controlled Medication Administration Record, it was observed that required initials/notes for prescribed medications were missing indicating that they were not properly dispensed which poses/posed an immediate risk to the health, safety, and personal rights of the residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: The facility designated Administrator stated that an audit of the facility medication administration records will be conducted for both the Assisted Living and Memory Care (Traditions) components. Training, for no less than (1) hour in duration, will be conducted on the topic of proper handling, dispensing, and documentation of all facility resident medications. A statement of correction, along with proof of updated medication training, will be completed and submitted into CCL by the due date. Proof of training will include name of trainer, training topic(s), and list of attendees.

Type of visit: Case Management - Legal/Non-compliance

Unannounced case management visit made out to this facility today by Licensing Program Analyst (LPA) Charlie Yang and Licensing Program Manager (LPM) Liza King, who were met by the facility Health and Wellness Director Afifa Kahn and Memory Care Director Jocelyn Ning and the purpose of the visit was explained. The designated Administrator Andrea Armstrong arrived at 9am. Current census was 92 residents, of which 27 resided in the memory care unit also referred to as Traditions. Currently there are 8 persons receiving hospice care, no residents require a hoyer lift. The purpose of this case management visit was to conduct a quarterly visit as outlined from the Non Compliance Conference held on 03/25/2024 and the requirement to have increased monitoring at that time. The focus of this quarterly visit was to review the following items that were initially brought forth on 03/25/2024: Medication Errors addressed in report Staffing Concerns addressed in report Reporting Requirements addressed in report Medication Training past 3 months has been sent via email to Charlie.Yang@dss.ca.gov for review Facility Polices Regarding: Assessments, Monitoring of Residents, Change in Condition, Medication Errors - any inservices related to the above over the pst 3 months to be sent via email to Charlie.Yang@dss.ca.gov for review cont. A tour of the Traditions neighborhood was conducted. LPM King observed breakfast meal service consisting of eggs, bacon, sausage, pancakes and cereal. Residents appeared groomed and ready for the day. LPM verified doors that required to be secured were, the area appeared clean with no presense of odor. A tour of all hospice rooms in the Traditions area was conducted as well as well as 4 additional rooms. Rooms were clean without clutter or odor, no toxins were present. Staff consisted of a Memory Care Director, three caregivers, one housekeeper and one medtech in the Traditions area upon arrival. Interview confirmed this is usual staffing except on weekends when there are one additional caregiver on each shift in case of call offs. A copy of the Aug schedule and hours worked log was requested for review. The schedule shows 3 care givers and 1 medtech scheduled both AM and PM shift and 1 caregiver and 1 medtech for the overnight shift. According to interview with staff there are 10 residents in the Traditions area that require 2 person assistance. According to interview with the Administrator although this is a preference of staff there are 4 careplans that require 2 person assistance, the Health and Wellness Director confirmed this. Staff schedule for the month of Aug was reviewed. Staff hours worked during the month of Aug were reviewed. On one of four days reviewed during the month of Aug care staff were 2 for am and 2 for pm shifts. Admin reported that when there is a shortage of care staff then the Memory Care Director is to provide assistance with care on the floor. During the visit, the care logs were not verified to show if the MCD provided care. This will be looked at on a future visit. Based on the staff schedule there is one CG on NOCs and one Med Tech assigned to the Traditions area. Per interview with the Admin the caregiver from the Asissted Living side is called to the Traditions area to assist when needed. Additionally, the MedTech is available to assist with care. Lunch meal service was observed. The shower log was reviewed for the current month which showed one missed shower (resident refused). ADL logs were reviewed for AM, PM and overnight shifts for the month of September which document dressing, bathing, grooming toileting and transfer assistance all being provided. cont. Four resident files were reviewed as a result of incident reports received in the Regional Office (RO). R1 sustained 5 falls over the past 3 months. The RO received 2 IRs for the month of September. Fax conformation was provided for falls that occurred during July and Aug. All care plans were updated. R2 remains out of the community and further follow up is necessary. For R3 the RO is requesting the facility obtain the Death Certificate and forward it to the RO. Additional follow up may be necessary. IR received in the RO for the incident. R4 5 IRs related to falls were provided while at the facility for the months of July, Aug, and September. During a file review the LPM revealed 3 additional falls during the month of Aug. According to the Admin falls without injury or ER visit do not result in an incident report being submitted to the RO. Based on documentation the resident has fallen 8 times over the review period. The Care Plan was updated one time dated 08/25/2025. Per conversation with Admin no additional interventions are needed at this time. The RO received one incident report. Fax confirmation was provided at todays visit for the additional IRs. LPM reviewed the Physicians orders and MARS for the months of July, Aug and September for four residents in Traditions (R6, R7, R8, R9). Prn medication provided and effectiveness were documented. R6 all medications were signed off. R7 medications were not signed of for the PM on 08/02/2025, incident was reported to the RO, no other missed medications. R8 PM medications missed on 08/02/25 and reported to the RO. Additionally, melatonin missed on 08/03 and 08/04, breathing treatment was missed on 08/16 due to facility awaiting Rx to be delivered. Again, this occurred on 09/06, 9/23, 09/24 and 09/25; medications pending refill delivery. R9 no missed medications. Technical Assistance was provided as 3 of 4 resident Centrally Stored logs were not completed. LPM reviewed Controlled Substance logs which were complete, 12 bottles pulled and compared to the Centrally stored log and 5 counts were completed with no concerns noted. A follow up visit will occur at a later date to review Centrally Stored logs again. Citations were issued today in relation to a complaint received regarding mismanagement of medications. The findings from todays visit are being incorporated into that finding. NO citations are being issued as a result of this visit. An Exit interview was conducted with Andrea Armstrong, Afifa Kahn and Jocelyn Ning and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 25, 2025

Type of visit: POC

Unannounced Plan of Correction visit made out to this facility on 07/14/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Andrea Armstrong. A brief interview was conducted with the facility designated Administrator at this time. Current census was 97 residents.. The purpose of this visit was to follow up on the deficiencies that were cited from a prior case management visit/Legal Non Compliance conducted on 06/19/2025. This visit was to follow up on the Plan of Correction that was due. The following deficiencies were observed and cited on 06/19/2025: A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: Plan of Correction clearance letter was printed and a copy was provided to the facility designated Administrator at this time. There were no further deficiencies observed or cited during today's Plan of Correction visit. Exit Interviewthe state’s words, verbatim · CDSS document, Jul 14, 2025

Type of visit: Case Management - Legal/Non-compliance

Unannounced case management visit made out to this facility on 06/19/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Andrea Armstrong, at this time. A brief interview was conducted with the facility designated Administrator at this time. Current census was 97 residents, of which 29, resided in the memory care unit also referred to as Traditions. The purpose of this case management visit was to conduct a quarterly visit as outlined from the Non Compliance Conference held on 03/25/2024 and the requirement to have increased monitoring at that time. The focus of this quarterly visit was to review the following items that were initially brought forth on 03/25/2024: Medication Errors Staffing Concerns Reporting Requirements Medication Training Facility Polices Regarding: Assessments, Monitoring of Residents, Change in Condition, Medication Errors A tour of the memory care unit, Traditions, was conducted. A review of the living areas, dining area, and all other areas intended for resident use was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. A tour of the assisted living medication room was conducted. This LPA was met by the current medication technician on duty who was interviewed at this time. Policies and procedures involving the handling, dispensing, and documentation of the resident medications were discussed with the present medication technician at this time. A review of the facility Medication Administration Record was conducted. It was observed that this facility currently employed an electronic Medication Administration Record (E-MAR) system as well as documenting on forms and documents as well. A review of the facility narcotics policies and procedures was conducted. In addition, a review of the Controlled Medication Administration Record for the resident narcotics was conducted. It was observed by this LPA that on 05/05/2025, 05/17/2025, and 06/01/2025 that there were more than the required (3) entries for the narcotics count which were performed by the oncoming shift medication technician and the off going shift medication technician. This was observed to be evident on 05/05/2025 which had (4) entries and 05/17/2025 had a total of (5) entries made on the narcotics count log. On 06/01/2025, it was observed by this LPA that there were only (2) entries made for that day for the AM and Evening shifts and the Night shift did not have an entry for either the oncoming or off going medication technicians. A tour of the memory care unit medication room was conducted. This LPA was met by the current medication technician on duty who was interviewed at this time. Policies and procedures involving the handling, dispensing, and documentation of the resident medications were discussed with the present medication technician at this time. A review of the facility Medication Administration Record was conducted. It was observed that this facility currently employed an electronic Medication Administration Record (E-MAR) system as well as documenting on forms and documents as well. A review of the facility narcotics policies and procedures was conducted. In addition, a review of the Controlled Medication Administration Record for the resident narcotics was conducted. A review of the assigned tasks and duties for caregivers to complete for all three shifts (AM, PM, NOC or referred to as Day, Evening, and Night) was reviewed for proper documentation and notation at this time. It was observed by this LPA that there were a total of (7) days ranging from 04/01/2025 through 06/01/2025 where there were not the required (3) entries for AM, PM, and the NOC shift or referred to as the Day, Evening, and Night shifts from this facility. It was observed that on 04/27, 04/28, 05/05, 05/12, 05/19, and 05/21/2025 there were only (2) narcotics counts made for that day missing one from either the Day, Evening, or Night shifts. It was observed that on 04/26/2025, there were a total of (4) entries made for that day with duplicate entries filled in by the responsible staff persons. In addition, the Staff Assignments by Month by Responsible Party/Resident Name for the month of June 2025 was reviewed by this LPA. It was observed that entries were made into this binder for future dates by the care staff when the assigned duties had not even been completed yet. It was also observed that the caregivers did not properly fill out and initial into this binder when the assigned tasks had been completed for that corresponding day. The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. A civil penalty was assessed in the amount of $1000 for a repeat violation on the following LIC 421 IM. Appeal Rights were printed and a copy was given to the facility designated Administrator Andrea Armstrong at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Jun 19, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 20, 2025

Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: Based on a review of the facility medication administration record (MAR) and Controlled Medication Administration Record, it was observed that required names/initials for narcotics counts were missing, dates were omitted or incorrect, and medications were not dispensed as prescribed which poses/posed an immediate risk to the health, safety, and personal rights of the residents in care.the state’s words, verbatim · CDSS document, Jun 19, 2025

Plan of correction: The facility designated Administrator stated that an audit of the facility medication administration records will be conducted for both the Assisted Living and Memory Care (Traditions) components. Training, for no less than (1) hour in duration, will be conducted on the topic of proper handling, dispensing, and documentation of all facility resident medications. A statement of correction, along with proof of updated medication training, will be completed and submitted into CCL by the due date. Proof of training will include name of trainer, training topic(s), and list of attendees.

Type of visit: POC

Unannounced Plan of Correction visit made out to this facility on 06/19/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Andrea Armstrong. A brief interview was conducted with the facility designated Administrator at this time. Current census was 97 residents.. The purpose of this visit was to follow up on the deficiencies that were cited from a prior complaint visit conducted on 04/28/2025. This visit was to follow up on the Plan of Correction that was due. The following deficiencies were observed and cited on 04/28/2025: In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Plan of Correction clearance letter was printed and a copy was provided to the facility designated Administrator at this time. There were no further deficiencies observed or cited during today's Plan of Correction visit. Exit Interviewthe state’s words, verbatim · CDSS document, Jun 19, 2025

Allegation investigated: Staff did not provide activities to residents in care

Unannounced complaint visit made out to this facility on 04/28/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Andrea Armstrong. A brief interview was conducted with the facility designated Administrator at this time. Current census was 93 residents. The purpose of this visit was to deliver the findings from this investigation to this facility, and its representative, at this time. Based on a review of the facility posted activities calendar for each month, it was observed that activities for the memory care unit, Traditions, usually started as early as 0900 in the mornings and held events after lunch and in the evening hours. It was also observed that outings were sometimes offered on Friday evenings as well. Based on further review, it was learned that this facility also offered scenic drives for the facility residents depending on the weather and overall participation rate. Based on a review of the forms and documents provided to this LPA by this facility, it was learned that this Unsubstantiated facility maintained a sign up sheet and took attendance for all residents living in the Traditions unit who attended and took part in these activities throughout the day. It was observed that participation was always voluntary but residents were always encouraged to engage as much as they could depending on their physical and mental limits and abilities. It was observed that the lowest number of participants would range from 7-10 participants for any given activity and go up to as high as a 60% participation rate depending on the event and mood of the residents during that time. It was observed that activities were being offered to the residents in the Traditions unit on a daily basis but that the residents still had the right to refuse or participate if they chose to do so. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. Exit Interview learned that each shift of caregivers, (AM, PM, and NOC), were expected to document and initial the Staff Assignments by Month by Responsible Party at the end of their scheduled shifts. It was also learned that the responsible caregivers for each shift could also initial on this document as the staff assignments were completed throughout their shifts. Based on a review of this document conducted for the month of April 2025, all shifts, (AM-Day, PM-Evening, and NOC-Night), the focus was done just for the staff assignment for the task of Toileting. It was observed that there were several days on the AM-Day shift, as well as, the NOC-Night where initials were missing with no explanation or notations provided at this time. Based on interviews conducted, it was learned that the expectation was that all caregivers were supposed to initial when the staff assignments were completed. It was learned that there should not have been any missing or blank entries throughout all shifts for staff assignments and if there were to be any blank spots then there should have been a circle with an explanation attached. It was observed that these blank spots where staff initials should have been did not have any corresponding documents or information explaining the reason for the blank spots. Based on interviews conducted, it was learned that facility personnel would be considered, and deemed, to not have performed those assigned tasks if they did not properly initial into that day for that particular facility resident. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Apr 28, 2025 · control 27-AS-20241219144803

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(2) · Plan of correction due date: Apr 29, 2025

In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. The facility was found to be deficient as evidenced by the presence of incomplete forms and documents for staff assignments not being properly filled out and initialed when tasks for proper care and supervision to the residents were completed which posed an immediate threat to the Health, Safety, and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Apr 28, 2025

Plan of correction: The facility designated representative stated that all facility care staff providing care and supervision to the residents in care will undergo training, for no less than (1) hour in duration, on the topic of incontinence care including proper documentation. A statement of correction, along with proof of updated training, will be completed and submitted into CCL by the due date. Proof of training will include the name of the trainer, topic(s) of discussion, and a list of all attendees.

Type of visit: POC

Unannounced Plan of Correction visit made out to this facility on 04/28/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Andrea Armstrong. A brief interview was conducted with the facility designated Administrator at this time. Current census was 93 residents.. The purpose of this visit was to follow up on the deficiencies that were cited from a prior complaint visit conducted on 02/21/2025. This visit was to follow up on the Plan of Correction that was due. The following deficiencies were observed and cited on 02/21/2025: A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: Plan of Correction clearance letter was printed and a copy was provided to the facility designated Administrator at this time. There were no further deficiencies observed or cited during today's Plan of Correction visit. Exit Interviewthe state’s words, verbatim · CDSS document, Apr 28, 2025

Type of visit: Case Management - Incident

Unannounced Case Management visit made out to this facility on 04/28/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Andrea Armstrong. A brief interview was conducted with the facility designated Administrator at this time. Current census was 93 residents.. The purpose of this visit was to follow up on a report of a facility resident requiring care and supervision related to a Restricted Health Condition. This visit was conducted to make sure that there was a facility care plan set into place with the appropriate level(s) of care and trained individuals involved within this care plan at this time. This review was conducted in order to be able determine if this facility was able to provide and assist with the proper level of care to this resident, R1, at this time. A review of the facility care plan was conducted for R1. There were no deficiencies observed or cited related to this case management visit at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Apr 28, 2025

Type of visit: Case Management - Legal/Non-compliance

Unannounced case management visit made out to this facility on 02/21/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Andrea Armstrong, at this time. A brief interview was conducted with the facility designated Administrator at this time. Current census was 92 residents, of which 29, resided in the memory care unit also referred to as Traditions. The purpose of this case management visit was to conduct a quarterly visit as outlined from the Non Compliance Conference held on 03/25/2024 and the requirement to have increased monitoring at that time. The focus of this quarterly visit was to review the following items that were initially brought forth on 03/25/2024: Medication Errors Staffing Concerns Reporting Requirements Medication Training Facility Polices Regarding: Assessments, Monitoring of Residents, Change in Condition, Medication Errors A tour of the memory care unit, Traditions, was conducted. A review of the living areas, dining area, and all other areas intended for resident use was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. A tour of the memory care unit medication room was conducted. This LPA was met by the current medication technician, Lakena Touch, who was interviewed at this time. Policies and procedures involving the handling, dispensing, and documentation of the resident medications were discussed with the present medication technician at this time. A review of the facility Medication Administration Record was conducted. It was observed that this facility currently employed an electronic Medication Administration Record (E-MAR) system as well as documenting on forms and documents as well. A review of the facility narcotics policies and procedures was conducted. In addition, a review of the Controlled Medication Administration Record for the resident narcotics was conducted. A review of (10) facility resident files was conducted at this time and noted on the following LIC 858. The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. A civil penalty was assessed in the amount of $250 for a repeat violation on the following LIC 421 FC. Appeal Rights were printed and a copy was given to the facility designated Administrator Andrea Armstrong at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Feb 21, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 22, 2025

Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: Based on a review of the facility medication administration record (MAR) and Controlled Medication Administration Record, it was observed that required names/initials for narcotics counts were missing, dates were omitted or incorrect, and medications were not dispensed as prescribed which poses/posed an immediate risk to the health, safety, and personal rights of the residents in care.the state’s words, verbatim · CDSS document, Feb 21, 2025

Plan of correction: The facility designated Administrator stated that an audit of the facility medication administration records will be conducted for both the Assisted Living and Memory Care (Traditions) components. Training, for no less than (1) hour in duration, will be conducted on the topic of proper handling, dispensing, and documentation of all facility resident medications. A statement of correction, along with proof of updated medication training, will be completed and submitted into CCL by the due date. Proof of training will include name of trainer, training topic(s), and list of attendees.

Type of visit: Case Management - Deficiencies

Unannounced case management visit made out to this facility on 02/06/2025 by Licensing Program Analyst (LPA) Charlie Yang to follow up on a substantiated allegation from prior complaint investigation, 27-AS-20231107162650, and was met by the facility designated Administrator, Andrea Armstrong, at this time. This LPA met with the facility designated Administrator, Andrea Armstrong, and explained the purpose of the visit. On January 17, 2024, the Department concluded a complaint investigation, which alleged the following: “Facility failed to provide care and supervision.” The licensee was cited for California Health and Safety Code section 1569.312(e) Basic Services Requirements. This Licensee failed to monitor Resident (R1) to ensure their general health, safety, and well-being. R1 was found naked on the ground of their room after missing multiple meals. R1 was on the ground for an undetermined number of hours. At the time of the complaint visit that was conducted on January 17, 2024, an immediate civil penalty of $500.00 was issued and the Licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code Section 1569.49. The Department has concluded an analysis and has determined that a civil penalty was warranted for serious bodily injury. The Welfare and Institutions Code section 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 was evidenced by information gathered through medical records and interviews that the Licensee did not ensure R1 was provided proper care and supervision. As a result, R1 remained lying on the floor for an extended period of time, sustained serious bodily injury requiring R1 to be hospitalized, and had to receive additional care from a rehabilitation center. Today, 02/06/2025, the Department will be issuing a civil penalty per Health and Safety Code Section 1569.49(f) for a violation that the Department constituted as a serious bodily injury in the amount of $10,000.00. However, since an immediate civil penalty in the amount of $500.00 was previously issued on January 17, 2024, the amount of the civil penalty issued today will be for $9,500.00. A copy of this report, along with a copy of the LIC 421D, was provided to the facility designated Administrator, Andrea Armstrong, at this time. Appeal rights were printed and a copy was given to the facility designated Administrator, Andrea Armstrong, at this time. Exit interviewthe state’s words, verbatim · CDSS document, Feb 6, 2025

Type of visit: POC

Unannounced Plan of Correction visit made out to this facility on 12/23/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Andrea Armstrong. A brief interview was conducted with the facility designated Administrator at this time. Current census was 93 residents.. The purpose of this visit was to follow up on the deficiencies that were cited from a prior complaint visit conducted on 12/12/2024. This visit was to follow up on the Plan of Correction that was due. The following deficiencies were observed and cited on 12/12/2024: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. Plan of Correction clearance letter was printed and a copy was provided to the facility designated Administrator at this time. There were no further deficiencies observed or cited during today's Plan of Correction visit. Exit Interviewthe state’s words, verbatim · CDSS document, Dec 23, 2024

Allegation investigated: Staff are not properly isolating residents in care. Staff do not ensure restrooms have toiletries. Staff do not ensure facility is kept clean and sanitized.

Unannounced complaint visit made out to this facility on 12/12/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Andrea Armstrong. A brief interview was conducted with the facility designated Administrator at this time. Current census was 93 residents. The purpose of this complaint visit was to complete this investigation and present the findings to this facility, and its representative, at this time. Based on a review of the forms and documents collected during the course of this investigation, it was learned that this facility used a vendor, Ecolab, for obtaining cleaning and maintenance supplies. In addition, another vendor, HD Supply, was used to obtain toiletries and trash bags as needed. It was observed that these orders were done on a monthly basis but it was also observed that additional orders were completed within the same month if more items were needed at that time. A review of the facility restrooms was conducted. It was observed by this LPA that they contained an adequate supply of hand washing soap, paper towels, and toilet paper at this time. Unsubstantiated Based on a review of the facility policies and procedures in regards to Infection Control, the version that was submitted into CCL was last updated on 03/23/2022. It was observed that there was a section, Infection Control-17, which did outline the policies and procedures for Respiratory Illness Outbreak. This particular section of the facility Infection Control Policy was last updated on 12/15/2021. It was observed that this section of the Infection Control Policy did address the need for isolation for the residents, and staff alike, if deemed to be infectious and a threat to the Health, Safety, and Personal Rights of the residents in care. Based on a review of the forms and documents submitted into CCL, it was learned that facility staff were originally on boarded for a duration of 4 weeks after date of hire. The number of hours for the first 4 weeks of training amounted to total of 41 hours. It was learned that 2 hours of the overall 41 hours were dedicated to Personal Protective Equipment (PPE) and Infection Control and Prevention. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred. There were no deficiencies observed or cited during todays complaint visit. Exit Interviewthe state’s words, verbatim · CDSS document, Dec 12, 2024 · control 27-AS-20240826133118

Allegation investigated: Licensee does not ensure that staff are adequately trained. Staff do not ensure that resident is administered medication(s) according to physician's instructions. Staff do not ensure that residents' medications are ordered on a timely basis. Staff retaliated against resident in care.

Unannounced complaint visit made out to this facility on 12/12/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Andrea Armstrong. A brief interview was conducted with the facility designated Administrator at this time. Current census was 93 residents. The purpose of this complaint visit was to complete this investigation and present the findings to this facility, and its representative, at this time. Based on a review of the forms and documents submitted into CCL, it was learned that facility staff were originally on boarded for a duration of 4 weeks after their date of hire. The total number of hours for the first 4 weeks of training amounted to a total of 41 hours. It was learned that 2 hours out of the overall 41 hours were dedicated to Personal Protective Equipment (PPE) and Infection Control and Prevention training. Based on a review of the facility medication room located on the first floor, It was learned that resident medications were centrally stored in mobile carts that were observed to be locked and made inaccessible to the residents at this time. Unsubstantiated Based on a review of the facility policies and procedures for medication management, facility staff classified as medication technicians were tasked with handling, dispensing, and documentation of the resident medications. It was learned that this facility employed an electronic medication administration record (E-MAR) system which required medication technicians to log in, verify that the medications corresponded to the correct resident, and initialed into this system after dispensing the medications to the residents in care. A review of this E-MAR system was conducted at this time. It was learned that there were facility residents who were prescribed narcotics by their attending licensed medical professional as well. Based on a review of the policies and procedures for handling, dispensing, and documentation of the resident narcotics, it was learned that the incoming shift would always conduct a count with the outgoing shift to make sure that the dispensed dates were correct, narcotics count numbers were aligned, and any changes or re-orders were addressed at that time. A review of the narcotics medication administration record was conducted at this time. It was learned that there were a total of 29 facility residents who did not require their medications to be centrally stored by this facility and it's staff. It was learned that these residents were deemed capable by their licensed medical professionals to be able to store and self care with their medications at this time. Based on interviews conducted during the course of this investigation, it was learned that there weren't any issues in regards to staff retaliating against facility residents at any time. It was learned that there have not been any incidents reported to this facility at this time. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred. There were no deficiencies observed or cited at this time. Exit Interview It was learned that for the caregivers currently employed at this facility, there were 11 put onto the AM shift (0600 to 1430 hours). It was learned that there were 10 put onto the PM shift (1400 to 2230 hours) and 4 scheduled for the NOC shift (2200 to 0630 hours). It was learned that of the 11 facility caregivers scheduled for the AM shift, only 9 of them were considered to be full time who were scheduled to work 4-5 days a week. It was learned that 1 caregiver split their days with the PM shift and another caregiver only worked the weekends (Saturday and Sunday) only. It was learned that there were 4 Medication Technicians scheduled for the AM shift (0630 to 1430 hours). There were 3 Medication Technicians who were scheduled for the PM shift (2230 to 0630 hours) but these individuals split their days and were also scheduled with the AM shift. It was learned that these Medication Technicians would work 2 days on the AM shift and then work 3 days for the PM shift. It was learned that there was currently only one Medication Technician scheduled for the NOC shift (2200 to 0630 hours) at this time. This medication technician for the NOC shift was only on schedule 4 days a week at this time. It was observed that there wasn't another medication technician scheduled at this time to cover the other 3 days for the NOC shift. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was given to the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Dec 12, 2024 · control 27-AS-20240925092906

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 13, 2024

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This facility was found to be deficient as evidenced by a review of the facility personnel report which did not contain adequate staffing for all shifts at all times posing an immediate threat to the Health, Safety, and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: The facility designated Administrator stated that a plan will be developed to address the need for staffing for all shifts at all times. A statement of correction, along with the details of the staff hiring plan, will be completed and submitted into CCL by the due date.

Allegation investigated: Licensee does not ensure enough staff are present to prevent inappropriate interaction between residents.

Unannounced complaint visit made out to this facility on 12/12/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Andrea Armstrong. A brief interview was conducted with the facility designated Administrator at this time. Current census was 93 residents. The purpose of this complaint visit was to complete this investigation and present the findings to this facility, and its representative, at this time. Based on interviews conducted and a review of the forms and documents that were received during the course of this investigation, it was learned that R1 and R2 were both facility residents who were placed in the Memory Care Unit of this facility. It was learned that these residents were mainly diagnosed with some form of cognitive impairment by their licensed medical professionals. It was learned that these residents would often roam the memory care unit or pace the hallways without any particular purpose in mind. It was learned that other residents would not be able to recall certain memories from their life and would sometimes mistaken other residents for their family Unsubstantiated members or even loved ones at times. It was learned that some residents would even seek out other residents for comfort and support even though they had no familial ties or any past history with one another. It was learned that such was the case involving R1 and R2 in terms of seeking each other out and seeking comfort as well. It was learned that it was not a forced relationship and that they would even miss or look out for one another when one of them was not present. It was learned that both, R1 and R2, would make the initial attempt to hold each others hand when they initially spotted each other after a brief separation. It was learned that this was not a one-sided relationship where one individual was taking advantage of the other due to cognitive decline. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Dec 12, 2024 · control 27-AS-20241008143051

Type of visit: POC

Unannounced Plan of Correction visit made out to this facility on 12/12/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Andrea Armstrong. A brief interview was conducted with the facility designated Administrator at this time. Current census was 93 residents.. The purpose of this visit was to follow up on the deficiencies that were cited from a prior annual visit conducted on 10/17/2024. This visit was to follow up on the Plan of Correction that was due. The following deficiencies were observed and cited on 10/17/2024: The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. Each resident's record shall contain at least the following information: Plan of Correction clearance letters were printed and copies were provided to the facility designated Administrator at this time. There were no further deficiencies observed or cited during today's Plan of Correction visit. Exit Interviewthe state’s words, verbatim · CDSS document, Dec 12, 2024

Type of visit: Required - 1 Year

Unannounced annual visit made out to this facility on 10/17/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated representative, Asha Prasad, who was briefly interviewed. This LPA requested that she go ahead and contact the facility designated Administrator, Andrea Armstrong, to inform her that CCL was present at this time. It was learned that Mrs. Armstrong was unable to be present during today's annual visit. This annual visit was conducted with the facility Business Office Director, Asha Prasad, at this time. Current census was 96 residents. It was learned that there were (6) residents under the care of hospice at this time while (10) other residents were receiving services through home health as well. This facility does have a hospice waiver approved for (15) residents and fire cleared for bedridden and dementia care for residents at any given time. A tour of this facility was conducted. Administrator certificate was observed to be present for facility designated Administrator Andrea Armstrong at this time. Kitchen area was toured. Cabinets and drawers were reviewed. Food preparation stations, dishwashing station, and other areas intended for meal preps were toured. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe additional food storage units which were present and functional at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication rooms, located on each floor, were reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications were discussed with the facility designated medication technicians at this time. The medication carts were observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restroom was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. It was learned that there were several different floor plans for residents on the Assisted Living portion of this facility. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Linen closet, located in the facility laundry area, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time. A tour of the Memory Care portion was conducted. Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 04/18/2024 by the local fire extinguisher company, Alpha Fire Control, and in compliance at this time. First aid kits were observed to be present and contained all of the required components at this time. Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gates, and exits was conducted. A review of (10) facility resident files was conducted. A review of (10) facility personnel files was conducted. The following forms and documents were requested to be updated and submitted into CCL: LIC 308 LIC 400 LIC 500 LIC 610 The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code. Appeal Rights were printed and a copy was given to the facility representative, Asha Prasad, at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Oct 17, 2024

Type of visit: Case Management - Legal/Non-compliance

Unannounced case management visit made out to this facility on 10/17/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the Business Office Director, Asha Prasad, who was briefly interviewed at this time. Current census was 96 residents. The purpose of this case management visit was to follow up on the quarterly visits that were required since the last one that was conducted took place on 07/25/2024. The following items were required to be monitored and maintained in compliance at all times: Staffing Concerns: Job Fairs will be conducted and continuous hiring. Medication Errors: A medication error was reported to Community Care Licensing Department (CCLD) by the facility. Medication Audit: A medication audit was completed on July 18, 2024. Reporting Requirements: The Department has received incident reports from the facility. Medication Training: June 12, 2024 and July 15, 2024. Facility Policies Regarding: Assessments, Monitoring of residents, Change in condition, Medication errors. Polices provided to CCLD. This case management visit was conducted in conjunction with the required annual visit. All deficiencies were addressed and cited on the annual LIC 809-D. Appeal rights were also printed and given to the facility representative at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Oct 17, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit on 07/25/2024 at 9:00 AM. LPA Martinez met with Andrea Armstrong and explained the purpose of the visit. The purpose of the visit today is to conduct a quarterly visit. LPA Martinez followed up with the following: Staffing Concerns: Job Fairs conducted and continuos hiring. Medication Errors: A medication error was reported to Community Care Licensing Department (CCLD) by the facility. Medication Audit: A medication audit was completed on July 18, 2024. Reporting Requirements: The Department has received incident reports from the facility. Medication Training: June 12, 2024 and July 15, 2024. Facility Polices Regarding: Assessments, Monitoring of residents, Change in condition, Medication errors. Polices provided to CCLD. Quarterly Visit Review: Medication Error: Resident (R1) was given the wrong Metoprolol SUCC ER dosage. Per facility medication error communication note, R1 was administered the wrong dosage from June 06, 2024 to July 09, 2024. During the error medication review, it was learned R1 Medication Administrator Records (MAR) were not maintained. The February and May MAR had missing staff administration signatures: February 07, 2024-Metoprolo; May 23 and 25, 2024. LPA Martinez reviewed the MARs' caregiver notes for the missing administration signatures information, and there were no notes. LPA Martinez also requested new medication orders and discontinued medication orders for Metoprolol. The requested medication orders were not provided during today's visit. LPA Martinez was informed by staff that the orders would need to be requested from pharmacy. Continued... Facility staff will email medication orders to LPA Martinez by August 04, 2024. Because you have been cited for repeating the same violation within 12 months (California Code of Regulations Section 87465(a)(4)), a civil penalty in the amount of $1,000.00 shall be assessed 07/25/2024. Please refer to LIC 421IM form for additional information. Reassessments: LPA Martinez reviewed resident 2 (R2) assessments and health condition changes. LPA Martinez reviewed a March 21, 2024 pre-assessment and a March 21, 2024 individualized service plan (ISP). The pre assessment- skin care section stated, "resident has no skin impairment." The healing wounds/bedsores section states, "requires staff monitoring and assistance with care of healing wound/pressure injuries from licensed nurse. The ISP skin care section states, "resident has no skin impairment." Healing wound section states, "Resident has home health for left leg...left leg with redness and flaky skin with scabs...no open wounds." LPA Martinez reviewed a medical visit summary dated April 09, 2024. This summary indicated R1 had a right leg wound and required wound care. Medical summary visit also included physician orders: wear compression sock during the day; keep wound clean and dry; elevate legs whenever possible; water consumption 1.7 liters per day; and lower salt intake. LPA Martinez did not observer an updated April 2024 assessment to implement the April 09, 2024 physician orders and to include home health care. Also, the assessment did not clarify if R1 was diagnosed with a pressure injuries or wounds. LPA Martinez reviewed an ISP dated May 01, 2024. The skin care section states, "resident has no skin impairment." Healing wound section states, "resident has no healing wounds or pressure injuries." The May 01, 2024 ISP does not included R2's April 09, 2024 physician orders: wear compression sock during the day; keep wound clean and dry; elevate legs whenever possible; water consumption 1.7 liters per day; and lower salt intake. The assessment does not include if wounds have healed and does not indicate if R2's is receiving skin integrity observation/monitoring. Based on the facility file review, R2's assessment plan was not being updated and maintained. As a result, of today's quarterly visit, deficiencies can be found on the 809D page. An exit was conducted, and a copy of the 809 report, 809D Pagesthe state’s words, verbatim · CDSS document, Jul 25, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 25, 2024

87465(a)(4) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by: Based on interviews and file review: The Licensee did not ensure R1 was administered the correct Metoprolol dosage from 06/06/24 to 07/09/2024. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Facility Staff has conducted medication training on July 15 and will conduct a medication training by August 15. LPA Martinez was provided medication training materials on 07/25/2024. POC cleared at visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(a)(6) · Plan of correction due date: Aug 8, 2024

87465(a)(6) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility.When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement was not met as evidence by:Based on file review: The Feb & May MARs provided to LPA Martinez by Facility showed staff did not sign off on MARs for medication Metoprolol on May 23 and 25 & Feb 07 2024. This posed a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Facility Staff has conducted medication training on July 15 and will conduct a medication training by August 15. LPA Martinez was provided medication training materials on 07/25/2024. POC cleared at visit

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Sep 25, 2024

87463(a) Reappraisals: The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. This requirement was not met as evidence by: Based on interviews and file reviews, R2's assessments were not maintained and did not contain significant health changes and the assessments provided to LPA Martinez were not signed by RP, R2, or staff. This posed an immediate health and safety risk to R2.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Facility will conduct regular assessment audit for the next two months (September 25, 2024). Email LPA Martinez a bi-weekly update on audits. Email R2's assessment to LPA Martinez by August 09, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit on 07/23/2024 at 10:50 AM. LPA Martinez met with Andrea Armstrong and explained the purpose of the visit. The purpose of the visit today is to conduct a quarterly visit. LPA Martinez followed up with the following: Staffing Concerns: LPA Martinez will return to follow up on medication training. Medication Errors: LPA Martinez will return to the facility to follow up on medication error incident. Medication Audit: A medication Audit was completed on July 18, 2024 Reporting Requirements: The Department received a medication error incident report on July 17, 2024. Medication Training: LPA Martinez will return to follow up on medication training. Facility Polices Regarding: Assessments, Monitoring of residents, Change in condition, Medication errors. LPA Martinez will return to follow up on medication training. Quarterly Visit Review: LPA Martinez reviewed seven resident files and conducted interviews in regards to medication errors. LPA Martinez will follow up on the seven files at a later time. LPA Martinez will conduct a continuation quarterly visit. There were no deficiencies cited at this time, and exit interview was conducted. A copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 23, 2024

Type of visit: Case Management - Other

On 07/23/2024 Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an post continuation required inspection. LPA Martinez met with Andrea Armstrong and explained the purpose of the visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. Administrator holds current certificate. The facility has a total capacity of 136 residents, of which 8 may be bedridden. The facility has an approved hospice waiver for 15. There are currently 92 residents who reside at this facility. LPA Martinez conducted staff interviews during today's post required inspection. On the June 03, 2024 visit, LPA toured the facility, which included common areas, kitchen, resident rooms, outside courtyard, and restrooms. Additionally, LPA Martinez conducted medication room inspection. As a result of this continuation post licensing visit, the facility there were no deficiencies cited. An exit interview was conducted, and a copy of this 809 report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 23, 2024

Type of visit: Post Licensing

On 06/03/2024 Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an post required inspection. LPA Martinez met with Asha Prasad and explained the purpose of the visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. Administrator holds current certificate. The facility has a total capacity of 136 residents, of which 8 may be bedridden. The facility has an approved hospice waiver for 15. There are currently 92 residents who reside at this facility. The LPA Martinez toured the facility with Asha Prasad on 06/03/2024 at 12:00 PM. LPA Martinez reviewed five resident files and five staff files. Five out five resident files were complete. Four out of 5 staff files did not have a first aid certificate. LPA Martinez conducted a medication audit review with staff 1 (S1). During the medication audit, witness 1 brought a morphine sulfate syringe that expires on 05/01/25. It was learned an unused morphine Sulfate syringe was left in resident 1's (R1) room. Moreover, a facility staff signed the medication administration record (MAR) indicating the medication was administered to R1. In addition, the narcotic log sheet was signed off indicating the morphine syringe was administered and updating the medication count number. Additionally, the last fire drill was on 12/29/2023, which should be conducted every three months for Dementia residents. Due to insufficient time, a continuation post licensing visit will be required. LPA Martinez will return at a later time and date to complete the post licensing visit. As a result of this post licensing visit, the facility is not in compliance with Title 22 Regulations, and deficiencies can be found on the 809D page. An exit interview was conducted, and a copy of this 809 report, 809D page, appeals rights, and 811 page were provided to the facility.the state’s words, verbatim · CDSS document, Jun 3, 2024

Type of visit: Case Management - Incident

An unannounced case management visit was conducted by the Licensing Program Analyst (LPA) Avelina Martinez on 04/26/2024 at 1:20 PM. LPA Martinez met with the facility administrator Andrea Armstrong and explain the purpose of the visit. The purpose of the visit is to follow up on an incident reports received on February 07, 2024 and February 24, 2024 . Both incidents involved falls with injuries. LPA Martinez requested copies of the following documents for resident 1 and resident 2: Admission Agreement, Physician Report LIC 602, and Needs and service plan, reassessments, pre-placement/assessment, and hospital discharge summary reports. The requested documents should be emailed to LPA Martinez by 04/20/2024 5:00 PM. LPA Martinez will follow up on the incidents at a later date and time. No, deficiencies were cited at this time. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Apr 26, 2024

Type of visit: Case Management - Legal/Non-compliance

An Informal Non-Compliance Conference (NCC) was conducted today on March 25, 2024 via Microsoft Teams with the Sacramento South Regional Office at 1:30 PM. Present at today's meeting include the following: Licensing Program Manager Stephenie Doub, Licensing Program Manager Liza King, and Licensing Program Analyst Avelina Martinez: Facility Representatives: Andrea Armstrong, Scott Carlson, Sue Mcpherson, Elaine Wong, Joel Goldman; Ombudsman Representative: Kathryn Thomas. The Non-Compliance Conference process was explained during this meeting; also, to include the Administrative process. In the last year, the facility has been cited a total of six times. The facility received four A citations and two: B citations. The citations consist of the following: Care and Supervision and Incidental, reporting requirements, and incidental and medical. Issues discussed during the Non-Compliance Conference were: Complaint Number 27-AS-20231107162650- Lack of Care and Supervision Medication Errors Staffing Concerns Reporting Requirements Medication Training Facility Polices Regarding: Assessments, Monitoring of residents, Change in condition, Medication errors. Continued... The facility has stated they will do the following to achieve continued and substantial compliance: Submit facility medication training documentation and procedures to Community Care Licensing Department (CCLD) by 03/29/2024 by 5:00 PM Submit a recent hospital discharge notes, reassessment, updated medication orders, and staff training on care and service needs by 03/29/2024 5:00 PM Request Technical Support Program (TSP) if needed. Submit updated policy on resident checks/monitoring by 03/29/2024 5:00 PM Submit assessment procedures by 03/29/2024 5:00 PM In addition, at this meeting the Licensee and facility management were advised future non-compliance regarding the above and other regulatory components will result in additional citations, civil penalties, and further potential administrative action. Community Care Licensing Department (CCLD) will do the following: Increase monitoring to quarterly visits for 1 year. Technical Support Program (TSP) referral. (A referral will be completed when Licensee advises CCLD of TSP need). TSP website materials were emailed to Oakmont of Lodi staff. Technicalsupportprogram@dss.ca.gov 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. Per California Code of Regulations (CCRs) - Title 22 no deficiencies are being cited at this visit. An exit interview was conducted with facility staff, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.the state’s words, verbatim · CDSS document, Mar 25, 2024

Allegation investigated: Resident was not being given medications as needed.

Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 03/21/2024 at 12:45 PM to deliver complaint findings, LPA Martinez met with Andrea Armstrong and explained the purpose of the visit. Throughout the course of the investigation, LPA Martinez conducted interviews and reviewed facility documents. It was learned resident 1 (R1) was sent to the Emergency Room (ER) on October 27, 2023. R1 returned to Oakmont of Lodi facility on November 15, 2023. Upon return, R1 required a higher level of care. R1 was reassessed and their Individualized Service Plan (ISP) was updated. R1 required Medication Management Services. The ISP states the following: " Requires medication assistance with 1 to 5 medications including all oral, topical, inhalers, drops, patches, supplements and PRN medications... medication storage included... expected result: receives medication in a timely manner...task description: assist with medication administration as order." In addition, R1 was assessed 30 acuity points for medication management and 30 billable points. Continued... Substantiated LPA Martinez requested a copy of R1's medication administration record (MAR). LPA Martinez was informed by the facility Administrator that the facility does not have MARs for R1 on February 28, 2024. It was learned the facility did not administer medication to R1. Because you have been cited for repeating the same violation within 12 months (California Code of Regulations Section 87465(a)(4)), a civil penalty in the amount of $1,000.00 shall be assessed 3/21/2024. Please refer to LIC 421IM form for additional information. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted, and a copy of this report was provided to the facility. Additionally, R1 was refunded a total of $2,292.92 on December 19, 2023 to cover rent and care and supervision. This agency has investigated the complaint alleging (Facility did not adhere to resident's signed admission agreement). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Mar 21, 2024 · control 27-AS-20231215103201

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 22, 2024

87465(a)(4) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by: Based on file review and interviews, the Licensee did not ensure staff were administering medications to R1. This posed and immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: Facility is actively recruiting a Well Nurse to assist with Medication Compliance. Medication Training was recently provided in February, next training is next month. Medication audits are done every Thursday. A medication audit is scheduled for later today. Facility staff agrees to email LPA Martinez Training Agenda and Wellness nurse recruiting plan by 03/22/24 by 5:00 PM.

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Facility failed to provide care and supervision. Facility failed to seek timely medical care.

Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 01/17/2024 at 9:15 AM to deliver complaint findings, LPA Martinez met with Administrator, Andrea Armstrong, and explained the purpose of the visit. Throughout the course of the investigation, LPA Martinez conducted interviews, shadowed staff, toured the facility, and conducted file reviews. It was learned resident 1 (R1) slid off their bed onto the floor, and did not have their call button pendent at time due to R1 taking off their call button pendent. The time of incident was undetermined due to R1 not being checked on. The time frame of the incident is sometime between October 26, 2023 around 8:00 PM and October 27, 2023 at approximately 4:00 PM. Furthermore, it is unknown how long R1 was on the floor due to not being checked on. R1 was found by staff in their room on the floor naked on October 27, 2023. R1 sustained rug burns, skin tears, and bruising. R1 was sent to the Emergency Room (ER) and was later transferred to a skilled nursing facility (SNF). Continued... Substantiated As a result, the facility was not monitoring/ensuring R1's general health, safety, and well-being needs were being met. Moreover, the investigation revealed the facility was short staff during the AM shift (6:00 AM to 2:30 PM). During the AM shift, there was one med-tech and one care staff assigned to the Assisted Living unit. Throughout the investigation, LPA Martinez was informed AM staff did not check on R1. Additionally, R1 missed breakfast and lunch, and facility staff did not check on R1 after the missing meals. Facility staff conducted a safety check after the facility concierge received a phone call from R1's responsible party (RP). Care staff provided first aid care, assisted R1 off the ground, and helped dress R1. Facility staff called 911 after resident was found on the floor for an undetermined amount of hours. Due to the fact that the facility did not provide basic services to R1, the facility did not provided timely medical attention. As a result of this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D page, per Title 22 Regulations. Due to R1 sustaining serious bodily injury, the violation warrants civil penalty assessments. At this time, the civil penalty assessments are under review, and a civil penalty determination is pending by the Department. Once civil penalty assessments have been determined, an LPA will return at a future date to assess the civil penalties. An immediate $500.00 civil penalty shall be assessed on January 17, 2024; based on the fact the facility failed to provide basic care services to R1, which posed an immediate threat to the Health, Safety, and Personal Rights of R1. Please refer to 9099-D page for civil penalty: 1569.312(e) Basic services requirements. An exit interview was conducted, and a copy of this 9099 report, LIC 9099-D, and appeal rights were provided to the facility. Failure to correct any deficiencies by plan of correction due dates may result in civil penalties.the state’s words, verbatim · CDSS document, Jan 17, 2024 · control 27-AS-20231107162650

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(e) · Plan of correction due date: Jan 17, 2024

1569.312(e) Basic services requirements: Every facility required to be licensed under this chapter shall provide at least the following basic services: Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement was not met as evidence by: Based on file review and interviews, the Licensee did not ensure R1 was monitored daily. R1 was found on the ground unable to get up from the floor for hours due to lack of monitoring/basic services. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Jan 17, 2024

Plan of correction: The Administrator reported basic services training was conducted on 01/05/2023. POC was cleared at time of visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Jan 17, 2024

87465(g) Incidental Medical and Dental Care 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...This requirement was not met as evidence by. Based on file review and interviews, The Licensee did not ensure to seek timely medical attention for R1. R1 was not monitored/check on 10/27/23 and when R1 was checked on R1 was found naked on the ground, and R1 was on the ground for an undetermined amount of hours. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Jan 17, 2024

Plan of correction: The Administrator reported Incidental and medical training was conducted on 01/05/2023. POC was cleared at time of visit.

Allegation investigated: Staff is stealing resident's medication. Facility not following admission agreement by charging visitors for liquor.

On 01/17/2024 at 9:15 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Andrea Armstrong during today’s visit and explained the purpose of the visit. Throughout the course of this investigation, LPA Martinez conducted interviews, reviewed facility records, and conducted tours of the facility. LPA Martinez conducted a controlled drug administration audit with facility staff. The audit consisted of reviewing eight resident's controlled drug administration records. Facility staff counted the controlled medication during the audit, and the medication count was correct. There were no missing controlled medication during the audit on December 14, 2023. Continued... Unsubstantiated A records review of resident's 1 (R1) controlled drug administration record starting on November 12, 2023 thru December 11, 2023 indicated R1's Hydrocodone 5-325 MG medication tablet count was off, and missing one medication tablet, which was unaccounted for. However, there was not enough evidence to prove facility staff were stealing medication. Please refer to January 17, 2024 case management for incidental and medical deficiencies. Moreover, LPA Martinez reviewed resident 2's (R2) admission agreement, billing statements, and facility meal receipts. It was learned R2 was charged on $12.93 on December 04, 2022 for a meal that was not ordered by R2. Furthermore, LPA Martinez went over the incorrect charges with kitchen staff and the Administrator on December 14, 2023. At this time, it was confirmed R2 was charged incorrectly. The facility at this time is reviewing the charge, and will reimburse if needed. LPA Martinez reviewed R2's 2022 and 2023 Meal billing records and meal receipts. The meal receipts did not indicate R2 was being charged for alcoholic beverages. Therefore, there is not enough evidence to prove that R2 was being charged for alcoholic beverages. Furthermore, R2's admission agreement on page 21 states, " Alcohol is available for purchase in the bar and lounge and in the restaurant at dinner. See current pricing on the menus. Pricing may change or vary as menus change." According to R2's admission agreement R2 agreed to the alcohol services. Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegation are unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 17, 2024 · control 27-AS-20231114094113

Type of visit: Case Management - Deficiencies

An unannounced case management visit was conducted by the Licensing Program Analyst (LPA) Avelina Martinez on 01/17/2024 at 9:15 AM. LPA Martinez met with Andrea Armstrong and explain the purpose of the visit. The purpose of the visit is to follow up on learned deficiencies during complaint investigation 27-AS-20231114094113. Based to the investigation, the following deficiencies were learned: reporting requirements and incidental and medical. During 27-AS-20231114094113 investigation, it was revealed on November 24, 2023 at the AM shift, resident 1 (R1) was missing one 5-325 MG Hydrocodone tablet. An incident report was not provided to CCLD. The Hydrocodone 5-325 MG medication prescription was received on 11/12/2023 with 112 tablets. The first Hydrocodone tablet administered was on 11/12/2023 at 6:00 PM. The last Hydrocodone tablet administered was on 12/10/2023 at 7:00 AM. The facility requested an emergency supply of Hydrocodone on 12/10/2023 at 3:24 PM. R1's December 2023 Medication Administration Records (MAR) reported Acetaminophen 500 MG was administered on 12/10/2023 at 6:22 PM for pain. On 12/11/2023 at 7:26 AM Acetaminophen 500 MG was administered for pain, however, notes indicate R1 was still in a lot of pain. It was learned Hydrocodone was delivered on 12/11/2023, and the first Hydrocodone tablet administered was on 12/11/2023 at 6:00 PM. As a result, the facility did not follow Hydrocodone prescription orders and did not assist R1 with self administered medications as needed. Additionally, According to R1's November 2023 MAR, the following medications were not administered on November 16, 2023: Anastrozole 1 MG, Atorvastatin 10 MG, Docusate Sodium 100 MG, Hydrocodone-Acetamin 5-325 MG, Lisinopril 20 MG, and Metoprolol Tartrate 50 MG. Moreover, on November 23, 2023 Anastrozole 1 MG and Lisinopril 20 MG were not administered. In addition, the facility self reported to CCLD that staff administered the wrong medication to resident 2 (R2) on December 24, 2023. On December 24, 2023, resident 3 (R3) was administered the wrong medication, which was reported to CCLD by the facility. Continued... As a result, facility staff did not assist residents with self administered medications as needed. Due to this case management, The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, and a copy of the 809 report and appeal rights were given to the facility.the state’s words, verbatim · CDSS document, Jan 17, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 17, 2024

87465(a)(4) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by: Based on file review and interviews, The licensee did not ensure staff were administering R1, R2, and R3's medication as required and did not ensure staff were administering the correct medication to R2 and R3. This posed an immediate health and safety risk to R1, R2, and R3.the state’s words, verbatim · CDSS document, Jan 17, 2024

Plan of correction: The Administrator reported Medication Incidental and medical training was conducted on POC was cleared at time of visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(6) · Plan of correction due date: Jan 17, 2024

87465(6)Incidental Medical and Dental Care The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year... This requirement was not met as evidence by: Based on interviews and file reviews, The Licensee did not ensure MARs were being maintained for R1, R2, and R3. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 17, 2024

Plan of correction: The Administrator reported Incidental and medical training was conducted on 01/05/2023. POC was cleared at time of visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Jan 17, 2024

87211(a)(1)(D)Reporting Requirements each licensee shall furnish to the licensing agency such reports...Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidence by: based on interviews and file review the facility did not submit incident reports in regards to medication errors. This posed a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Jan 17, 2024

Plan of correction: The Administrator reported Reporting training was conducted on 01/17/2023. POC was cleared at time of visit.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Renee Campbell and LPA Victoria Brown, conducted an announced Pre-licensing visit on 10/04/2023 at 8:30am with Vice President of Operations Terry Evans, Representative for applicant Oakmont Senior Living of Lodi, OPCO LLC; Oakmont MG LLC, and the facility Administrator Andrea Armstrong. Administrator and Representative accompanied LPA’s on facility tour. As of today, the current census is 88 residents of which 7 are receiving hospice services, 76 are ambulatory, 12 are non ambulatory, and 0 are bedridden. The facility is a 96 bedroom, 100 bathrooms with a living room, dining room, kitchen, and laundry room. Residents have access to all areas. File reviews were conducted for 7 residents. LPA also reviewed 3 staff files. LPA measured the hot water in room 138 at 108 degrees Fahrenheit and room 246 at 107 degrees Fahrenheit. The kitchen was observed in good condition with properly stored perishable and non perishable foods. Prepared foods were covered in the refrigerator. The refrigerator was at 39 degrees Fahrenheit and the freezer was at -2 degrees Fahrenheit. LPA Campbell observed medications locked and properly stored. LPA observed no obstruction of emergency exits. Exit signs were in place as appropriate. Fire extinguisher located in the hallway was observed to be fully charged. First aid kit was observed to be present in the medication rooms and contained all required components at this time. Component III conducted - There are no objections to licensure at this time. -Licensure pending. An exit interview was conducted and a copy of this report was provided to Administrator Andrea Armstrong .the state’s words, verbatim · CDSS document, Oct 4, 2023