Oakmont of Redwood City

Type of visit: Case Management - Other

On 7/30/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to deliver an Amended version of an original complaint investigation report dated 7/16/2026. LPA Calandra was greeted by Jennifer Duenas, Executive Director and explained the purpose of the visit. LPA reviewed the Amended report with the Administrator and explained the reason for the Amendment. No deficiencies cited during today's visit. An exit interview was conducted and a copy of this report was provided to the Licensee whose signature confirms receipt of the report.the state’s words, verbatim · CDSS document, Jul 30, 2026

Type of visit: Case Management - Other

On July 21, 2026, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management visit. LPA met with Executive Director, Jennifer Duenas and explained the purpose of the visit. The purpose of this visit is to serve an exclusion letter for Staff 1 (S1). During the visit, Administrator confirmed that S1 is no longer employed with the facility and the licensee received a copy of the exclusion letter. No citations are issued during the visit. Report is reviewed and a copy is provided.the state’s words, verbatim · CDSS document, Jul 21, 2026

Allegation investigated: Staff sexually assaulted resident

**This is an amended version of the original report dated 7/16/2026, as a result of supervisory review. On 7/16/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to deliver conclusionary findings for this complaint received by the Department on 12/9/2025. LPA Calandra was greeted by Jennifer Duenas, Executive Director and explained the purpose of the visit. Complaint alleged that a individual employed by the facility(S1) sexually assaulted a resident(R1). Based on interviews and record review, S1 was instructed by a employee(S2) of the facility to supervise R1 while they watched tv. Upon S2's return from helping another resident, S2 observed S1 engaging in inappropriate behavior with R1. S2 immediately notified management who notified the police. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time. Substantiated An immediate civil penalty of $500.00 was issued. Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited on LIC 9099-D. Failure to correct the deficiency may result in civil penalties. At the time of the complaint inspection on 7/30/2026, licensee was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49. An exit interview was conducted. A copy of this report dated 7/30/2026 along with appeal rights were provided to the Licensee whose signature confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 14-AS-20251209100427

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jul 17, 2026

87464(f)(1) Basic Services: (f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews and record review, the Licensee did not ensure that R1 was provided proper care and supervision resulting in S1 having the opportunity to sexually abuse R1, which is an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 16, 2026

Plan of correction: Licensee will submit a plan of correction detailing how they will ensure the violation will not occur in the future. Administrator stated that they will conduct a training on the subject of care and supervision.

Allegation investigated: Staff did not follow physicians orders resulting in resident not receiving the correct medications

On May 21, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Administrator, Jennifer Duenas and explained the purpose of the visit. Regarding the allegation, staff did not follow physician's orders resulting in resident not receiving the correct medications, according to the reporting party, Resident 1 (R1) was no longer receiving Donepezil and was unsure why, was receiving an incorrect dosage of Lexapro and started receiving Olanzapine. Reporting party indicated, Donepezil should not have been discontinued in August 2025 as shown on the medication administration record (MAR) provided by the facility and Olanzapine should not have been given to R1. In addition, when R1 was admitted to the facility in July 2025, he/she was prescribed 5mg of Lexapro, the dosage increased to 10mg for Lexapro in September 2025, however does not believe the updated order was being followed. During the visit, LPA reviewed R1's file, including but not limited to; physician's orders for medication, medication list, and MAR. (continue to 9099C) Unsubstantiated Based on documents reviewed, the facility received an order from Pine Park Health on 8/8/25, instructing the facility to discontinue Donepezil, start Olanzapine (2.5mg) every day, and increase dosage of Lexapro to 10mg. Based on the MAR reviewed, R1 was receiving Donepezil since admission until August 8, 2025 when Pine Park Health instructed the facility to discontinue. MAR reviewed showed Olanzapine (2.5mg) and Lexapro (10mg) was being administered as prescribed. On August 19, 2025, a new order was sent from Pine Park Health to discontinue the Olanzapine and Lexapro. LPA reviewed R1's current MAR and current prescribed medication list, centrally stored medication list was up to date. Based on documents reviewed and information collected, the department has determined that although the above allegation may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with Administrator, Jennifer Duenas and a copy is provided.the state’s words, verbatim · CDSS document, May 21, 2026 · control 14-AS-20260406084011

Allegation investigated: Staff do not ensure resident's showering needs are being met Staff do not ensure the facility is clean and sanitary Staff do not ensure resident's laundry is being done Staff do not ensure resident's bedding is clean Staff are mismanaging resident's medication Staff do not respond to resident's calls for assistance Staff do not ensure resident's incontinence needs are being met Staff did not provide copy of resident's admission agreement to resident's representative

On May 11, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Jennifer Duenas and explained the purpose of the visit. Regarding the allegation, staff do not ensure resident's showering needs are being met, according to the reporting party, during frequent visits at the facility, it was observed that Resident 1 (R1) was not showered once. During the investigation, LPA interviewed staff and reviewed R1's file. LPA was unable to interview R1 as R1 passed away. Based on R1's physician's report, R1 is unable to bathe himself/herself and required caregiver assistance.. According to R1's service plan dated 12/18/25, R1 required hands-on assistance for all showering/bathing needs 1-2x/week. According to R1's charting notes and staff interviewed, there were several times, R1 refused showers. (Continue to 9099C) Unsubstantiated Regarding the allegation, staff do not ensure the facility is clean and sanitary, according to the reporting party, staff were not taking out R1's trash and it was overflowing. During the investigation, LPA reviewed R1's service plan and observed a random sample of rooms, including R1's room at the time. Based on observations, rooms were observed to be clean and odor-free. LPA did not observe trash on the room floors. Based on R1's service plan reviewed, R1 required no assistance beyond routine weekly housekeeping. According to staff interviewed, and R1's charting notes, R1 refused housekeeping/cleaning services. Regarding the allegation, staff do not ensure resident's laundry is being done, according to the reporting party, it was observed R1's laundry was sitting in a pile on the floor and was not done. During the investigation, LPA reviewed R1's file and interviewed staff. LPA was unable to interview R1 as R1 passed away. According to R1's service plan, R1 required weekly laundry service and independently manages additional laundry needs. According to staff interviewed, and R1's charting notes, R1 refused housekeeping/cleaning services. Regarding the allegation, staff do not ensure resident's bedding is clean, according to the reporting party, it was observed that R1's bedding was soiled. During the investigation, LPA toured and observed a random sample of rooms including R1's room at the time. and interviewed staff. LPA observed all rooms to have clean bedding. According to staff interviewed, laundry is done once a week per residency agreement, however if residents require laundry to be done more often then it would be added to their service plan. According to staff interviewed, and R1's charting notes, R1 refused housekeeping/cleaning services. Regarding the allegation, staff are mismanaging resident's medications, according to the reporting party, on 2/10/26, R1's hospice nurse called R1's responsible party to notify him/her that R1's morphine was missing and that R1 did not receive morphine for a week. (continue to 9099C) During the investigation, LPA reviewed R1's MAR, prescribed medication list, R1's medication destruction log and interviewed the Regional Operations Specialist. According to R1's MAR and prescribed medication list, R1 was prescribed morphine on 12/24/25 and received morphine by mouth every 2-4 hours as needed. According to documents reviewed, R1's physician ordered the facility to discontinue the administration of morphine for R1 on 1/1/26. Medication destruction log notes that the morphine was destructed on 2/26/26. Regarding the allegation, staff do not respond to resident's calls for assistance, according to the reporting party, there were days where R1's pendant was pressed, however no staff responded. During the investigation, LPA reviewed R1's call pendant log and interviewed residents. Based on R1's call pendant reviewed during the time R1 was a resident at the facility, the average response time was 18 minutes. According to residents interviewed, when they call for assistance, staff respond timely and help them. Regarding the allegation, staff do not ensure resident's incontinence needs are being met, according to the reporting party, R1 was wet from his/her waist to ankles and no one changed him/her, so the hospice nurse ended up changing R1. During the investigation, LPA reviewed R1's file and interviewed staff. LPA was unable to interview R1 as R1 passed away. Based on R1's physician's report, R1 is unable to care for his/her own toileting needs, wear depends and requires caregiver assistance. According to R1's service plan, R1 was occasionally incontinent of bladder and/or bowel and occasionally required staff assistance. According to R1's charting notes and staff interviews, there were several times, R1 refused to be changed by staff when his/her depends was soiled. Regarding the allegation, staff did not provide copy of resident's admission agreement to resident's representative, according to the reporting party, despite providing POA documents to the facility for R1, when he/she asked for R1's admissions agreement, the Director did not provide it and stated to get it from R1. During the investigation, LPA interviewed Regional Operations Specialist, and reviewed R1's file. (continue to 9099C) According to the Regional Operations Specialist, she denied this allegation and indicated that the individual that was asking for R1's admissions agreement did not provide any documentation to the facility to show that they were R1's responsible party or POA. In addition, based on R1's file reviewed, there were no POA documents and R1's emergency contact sheet signed on 12/3/25 did not list the individual who was requesting the admissions agreement nor did it list a medical POA. According to the Regional Operations Specialist, she provided R1 a copy of his/her admissions agreement and notified the individual that he/she can get it from R1. Based on documents reviewed, information collected, and interviews conducted, the department has determined that although the above allegation may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with Administrator, Jennifer Duenas and a copy is provided.the state’s words, verbatim · CDSS document, May 11, 2026 · control 14-AS-20260218102410

Allegation investigated: Facility is overcharging resident. Facility staff did not provide resident's responsible party with explanation of fee increases. Facility staff are not honoring the terms and conditions of the Admission Agreement.

On April 8, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with administrator, Jennifer Duenas and explained the purpose of the visit. Regarding the allegation, facility is overcharging resident and facility staff did not provide resident's responsible party with explanation of fee increases, according to the reporting party, the facility confirmed 152 care points for Resident 1 (R1), at the contract rate of $22 per point, which equals $3,344 per month, however, R1's invoices issued by the facility do not consistently reflect the confirmed care assessment that was established as R1's recent monthly care fees are showing $3640.75 per month. During the investigation, LPA reviewed R1’s file, reviewed R1’s accounting ledger and interviewed staff. According to R1’s file reviewed, R1 care assessment dated 11/21/2025, shows care point of 152. According to staff and documents reviewed, the contacted rate per point for R1 is $22. Based on R1’s accounting ledger for November and December of 2025, the care fees are observed at $3,640.75/month, however according to the Regional Director of Operations, a credit of $296.75 is being issued back to R1 because after Oakmont Management Company took over Sunrise Senior Living the billing is different. (continue to 9099C) Unsubstantiated Although the charge for care fees are being billed at $3,640.75/month, with the credit of $296.75 being applied, the total monthly care fees are $3,344/month. Based on the accounting ledger for R1, in October 2025, R1 was charged $3,640.75/month, however, was credited back $10.038.78. According to documents reviewed and interviews conducted, R1’s care level was higher prior to 7/1/2023 – date of transition and the care point assessed after the transition was at 177, which at the time totaled $3,434, which continued to be charged at that rate until January 2025. The care rate increased from $21 to $22 and all residents were transferred over from the 2024 assessment tool to the 2025 assessment tool for the new rate to take effect. That’s when the 2025 rate for care reflected $3,640.75. Because R1’s account was considered “legacy” his/her care rate was grand fathered in at the locked-in rate for the first 152 points and therefore, would generate a credit difference between the 2024 care rate and 2025 care rate. According to staff interviewed and emails reviewed, R1’s responsible party agreed to this care assessment and care amount of $3,434 on date of transition, 7/1/2023, however, Oakmont Management did not understand why refunds were being requested from R1’s responsible party. On 10/17/25, Oakmont’s Regional Director of Operations emailed R1’s responsible party and indicated that an immediate goodwill credit of $10,038.78 will be returned to R1’s responsible party. Regarding the allegation, facility staff are not honoring the terms and conditions of the admission agreement, according to the reporting party, Resident 1’s (R1’s) the facility is not honoring the billing terms tied to the care point system in the admission agreement with Sunrise Senior Living had. According to staff interviews and documents reviewed, after Oakmont Management Company took over Sunrise Senior Living the billing is different. Sunrise Senior Living calculated care in a different way to Oakmont and the translation of care services from Sunrise's point system to Oakmont's is a computer algorithm based on services provided. There's not a specific dollar per point during the transition from Sunrise. At that time, R1's care services equated to 152 points and that point total doesn't change unless R1 switches to an Oakmont residency agreement. Based on documents reviewed, information collected, and interviews conducted, the department has determined that although the above allegation may have happened or are valid, there is no a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is UNSUBSTANTIATED. Report is reviewed with Administrator, Jennifer Duenas and a copy is provided.the state’s words, verbatim · CDSS document, Apr 8, 2026 · control 14-AS-20260113152543

Allegation investigated: Staff did not ensure a resident's pendant was properly operating

On March 17, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced 10-day complaint visit. LPA met with Administrator, Jennifer Duenas and explained the purpose of the visit. Regarding the allegation, staff did not ensure a resident's pendant was properly operating, according to the reporting party, the computer system for the call pendants was down for several days and there was inadequate communication about the system being down. Reporting party indicated that not enough frequent checks were being provided for residents. During the investigation, LPA tested a random sample of resident's call pendants, interviewed staff, and reviewed documentation. Based on observations, call pendants were observed to be in good working condition. According to staff interviewed and documentation reviewed, after this issue was brought up to management, the facility immediately contacted Phillips Lifeline and started troubleshooting the system. (continue to 9099C) Unsubstantiated In addition, according to staff interviewed and documentation reviewed, the computer system for the call pendants were down for less than 24 hours. The facility immediately started taking steps to fix this issue as soon as it was brought up. Staff indicated that while the call pendants were in disrepair, the Regional Health Services Director implemented status checks on residents and staff increased resident checks to every 30 minutes to an hour or as needed based on resident needs. Based on documents reviewed, information collected, and interviews conducted, the department has determined that although the above allegation may have happened or are valid, there is no a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is UNSUBSTANTIATED. Report is reviewed with Administrator, Jennifer Duenas and a copy is provided.the state’s words, verbatim · CDSS document, Mar 17, 2026 · control 14-AS-20260310122944

Type of visit: Case Management - Other

On February 26, 2026, Licensing Program Analyst (LPA) Komal Curley conducted a Case Management-Other visit to the facility. LPA met with Regional Operations Specialist, Caroline Frangieh and explained the purpose of the visit. The purpose of this visit is to follow up on a "Decision and Order" for the exclusion of Staff 1 (S1) and Staff 2 (2) and revocation of administrator certificate for Staff (3). During the visit, Regional Operations Specialist confirmed that S1-S3 no longer are employed with the facility. No citations are issued during the visit. Report is reviewed with Operations Specialist, Caroline Frangieh and a copy is provided.the state’s words, verbatim · CDSS document, Feb 26, 2026

Type of visit: Required - 1 Year

On November 4, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced annual inspection. LPA met with Regional Operations Specialist, Tammie Sampedro and explained the purpose of the visit. LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageway was free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a two building facility; Assisted Living (AL) and Memory Care (MC). AL has three floors and MC has two floors. A random sample of resident rooms in AL and MC were toured. All resident rooms were observed clean, odor-free, equipped with all required furniture. Resident bathrooms and communal bathrooms were observed to clean and in good repair. Water temperature throughout the facility measured within regulatory requirements. Communal areas including but not limited to dining room, living rooms, private dining area, etc. were observed free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed two day perishables and seven day non-perishables. Medications, sharps, and chemicals were observed locked an inaccessible to residents in care. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of October 2024. Emergency drills are logged and done every three month. LPA reviewed 5 resident records and 5 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. No citations are issued during the visit. Report is reviewed with Regional Operations Specialist, Tammie Sampedro and a copy is provided.the state’s words, verbatim · CDSS document, Nov 4, 2025

Type of visit: Case Management - Other

On November 4, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case-management visit. LPA met with Regional Operations Specialist, Tammie Sampedro and explained the purpose of the visit. The purpose of today's visit is to deliver an immediate exclusion letter to exclude a Staff 1 (S1) from the facility. The letter was given to the Regional Operations Specialist, Tammie Sampedro. This report is reviewed and discussed with the Regional Operations Specialist, Tammie Sampedro and a copy is provided.the state’s words, verbatim · CDSS document, Nov 4, 2025

Allegation investigated: Staff did not ensure reporting requirements were followed

On October 22, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Regional Operations Specialist, Tammie Sampedro and explained the purpose of the visit. Regarding the allegation, staff did not ensure reporting requirements were following, according to the reporting party, after the alleged abuse incident that occurred on 10/3/25, the facility did not submit an incident report (LIC624) to CCLD and did not submit an APS report. Based on records reviewed and staff interviewed, there were no incident reports submitted to CCLD regarding the alleged abuse incident that occurred on 10/3/25. The facility was unable to provide any documentation to show that an incident report or an SOC341 was submitted to CCLD. Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Regional Operations Specialist, Tammie Sampedro and a copy is provided. Substantiatedthe state’s words, verbatim · CDSS document, Oct 22, 2025 · control 14-AS-20251009094007

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 23, 2025

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This regulation is not met as evidenced by: Based on records reviewed and staff interviewed, there were no incident reports submitted to CCLD regarding the alleged abuse incident that occurred on 10/3/25. The facility was unable to provide any documentation to show that an incident report or an SOC341 was submitted to CCLD which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 22, 2025

Plan of correction: Licensee to submit an in-service training regarding reporting requirements with staff who document LIC624s to submit to CCLD.

Type of visit: Case Management - Other

On October 22, 2025, Licensing Program Analyst (LPA) Komal Curley conducted a case management visit in relation to complaint #14-AS-20250113154240. LPA met with Regional Director Specialist, Tammie Sampedro and explained the purpose of the visit. Based on the course of the investigation, the reported resident checks for Resident 1 (R1) were random or every couple of hours and there was found to be no requirement to document or record when the checks were done, who conducted the checks, or what observations were made. Staff were unable to report any observations based on recall but claim these checks for R1 were conducted. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Regional Operations Specialist, Tammie Sampedro and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Oct 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87205(a)(b) · Plan of correction due date: Oct 23, 2025

87205(a)(b) Accountability of Licensee: The licensee, whether an individual or other entity, shall exercise general supervision…and establish policies concerning its operation in conformance with these regulations…to assure accountability. This requirement is not met as evidenced by: Based upon the administrator and facility staff interviews there is no definitive policy or documentation requirements for conducting resident checks as to date, time, observations or who conducted the resident checks for R1 or a means to ensure facility accountability which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 22, 2025

Plan of correction: Licensee to conduct an in-service training regarding resident care; including supervision, observation and documentation.

Type of visit: Case Management - Incident

On August 6, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit to follow up on a visit that was conducted on 7/22/25. LPA met with Interim Executive Director, Kathleen Olson and explained the purpose of the visit. On 7/12/25, the Licensee reported that on 7/9/25, it was alleged that Staff 1 (S1) took an unauthorized video of Resident 1 (R1) on S1's personal phone while R1 was sleeping in only his/her pull ups. It was heard on the video that S1 was laughing at R1 and called R1 a mermaid. In the video it was observed that S1 physically abused R1. On 7/12/25, Staff 2 (S2) reported this incident to management and indicated that S1 showed S2 the video. The facility was made aware of this incident on 7/12/25, however the administrator did not notify LPA of this incident until 7/17/25 via telephone. An SOC341 was not submitted to CCLD until 7/18/25 and an incident report was not submitted to CCLD until 7/21/25. The administrator failed to notify CCLD of the alleged abuse incident for 5 days after being aware of the incident. According to the administrator, there was a delay in reporting due to the incident being a hearsay incident and wanted to conduct an investigation prior to reporting to CCLD. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with the Interim Executive Director and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Aug 6, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(2) · Plan of correction due date: Aug 7, 2025

87405 Administrator - Qualifications and Duties: (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on interviews and record review, the administrator failed to notify CCLD of a alleged abuse incident that occurred on 7/9/25 and was made aware on 7/12/25, however did not notify CCLD for 5 days after being aware of the incident. Administrator did not submit an incident report to CCLD until 7/21/25 which poses and immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Licensee/administrator shall submit a plan on how to ensure incidents are reported to all required agencies in a timely manner.

Type of visit: Case Management - Other

On August 5, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit. LPA met with Interim Executive Director, Kathleen Olson and explained the purpose of the visit. The purpose of today's visit is to deliver an immediate exclusion letter to exclude Staff #1 (S1) from the facility. The letter was given to the Interim Executive Director, Kathleen Olson. This report is reviewed and discussed with the Interim Executive Director and a copy is provided.the state’s words, verbatim · CDSS document, Aug 5, 2025

Type of visit: Case Management - Incident

On July 22, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to an incident that occurred on 7/9/25, however was reported to CCLD on 7/12/25. LPA met with Interim Executive Director, Kathleen Olson and explained the purpose of the visit. On 7/12/25, the Licensee reported that on 7/9/25, it was alleged that Staff 1 (S1) took an unauthorized video of Resident 1 (R1) on S1's personal phone while R1 was sleeping in only his/her pull ups. It was heard on the video that S1 was laughing at R1 and called R1 a mermaid. In the video it was observed that S1 physically abused R1. on 7/12/25, Staff 2 (S2) reported this incident and indicated that S1 showed S2 the video. An investigation was conducted, however S1 resigned at the time of the investigation. During the investigation, LPA collected documents and interviewed staff. Further investigation is required. Report is reviewed with the Interim Executive Director and a copy of the report is provided.the state’s words, verbatim · CDSS document, Jul 22, 2025

Allegation investigated: Resident sustained unexplained fracture while in care.

On July 10, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Interim Executive Director, Kathleen Olson and explained the purpose of the visit. Regarding the allegation, resident sustained unexplained fracture while in care, according to the reporting party, on 10/13/24, it was observed the Resident 1 (R1) was in distress, complaining of pain in his/her groin area. In addition, the reporting party indicated, after transporting R1 to the hospital, various tests and an X-ray revealed a fracture on the left side of his/her pelvis. The reporting party reported that the staff at the facility did not know how or when the fracture occurred. During the investigation, the Department reviewed R1's file, interviewed staff and reviewed R1's medical records. According to R1's file reviewed, R1 was evaluated at low risk for falling, however staff interviewed thought R1 had fallen at an earlier date but were not able to provide details and there was no documentation of a fall. (continue to 9099C) Substantiated In addition, staff interviewed had conflicting information on whether R1 was a fall risk or not. Facility staff were unaware of R1's injuries and did not document or notice any changes in condition nor how the injury could have been sustained. Based on medical records, on 10/13/24, R1 was transported to the hospital and three x-ray views of R1's left hip did not show any fracture at the time. Further evaluation with cross-sectional imagining was recommended and conducted on 10/16/24 where a computed tomography (CT) scan was conduct of his/her left hip for a possible fall. Medical documentation indicated that the CT scan showed that R1 had an acute non-displaced fracture through the base of the left superior pubic ramus and through the mid left inferior pubic ramus. Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Failure to correct said deficiencies may result in additional civil penalties. AN IMMEDIATE CIVIL PENALTY OF $500.00 WAS ASSESSED TODAY: $500 FOR THE VIOLATION AS R1 SUSTAINED UNEXPLAINED FRACTURE WHILE IN CARE. A repeat civil penalty of $500 was issued today due to the same violation being cited on 5/27/25. Due to immediate civil penatly of $500 being cited and repeat civil penalty of $500 being cited, total civil penalty being issued today is $1,000 THE INTERIM EXECUTIVE DIRECTOR WAS INFORMED THAT AN ADDITIONAL CIVIL PENALTY IS STILL BEING DETERMINED AND MIGHT BE ASSESSED BASED ON HEALTH AND SAFETY CODE §1569.49. Report is reviewed with the Interim Executive Director and a copy is provided with appeal rights. Regarding the allegation, facility staff are not cleaning resident's room, according to the reporting party, on 10/13/24, it was observed that R1's room was filthy, with soiled bed linens, old, soiled clothing, and urine pads on the floor. During the investigation, LPA toured the facility and observed a random sample of eight resident rooms including R1's room. Based on observations, rooms toured were observed to be clean, odor-free, and with clean bed linens. During the visit, LPA was notified that R1 was no longer a resident at the facility. According to staff interviewed, there are two housekeepers on shift in the AM and two housekeepers in the PM. Housekeepers are deep cleaning rooms every week, taking out trash from resident's room per shift and doing laundry as needed. In addition, staff interviewed indicated that every shift change, caregivers will check each resident rooms to make beds and collect trash at the beginning and at the end of each shift. Regarding the allegation, facility staff did not communicate with authorized representative(s) on resident changes in health condition, according to the reporting party, the facility staff did not know how or when R1 suffered a fracture and did not notify R1's authorized representative of any injuries or changes in condition. During the investigation, staff were interviewed and R1's charting notes were reviewed. Based on charting notes, there was no notes that indicated R1 had a fall or a change of condition. According to staff interviewed, they were unaware why R1 was sent to the hospital on 10/13/24 and indicated they did not see or here about R1 having a fall before or on 10/13/24. Additionally staff interviewed also indicated that they did not observe any changes in R1's condition or R1 complaining of pain prior to being sent to the hospital. Based on interviews conducted, interviews conducted and documents reviewed, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed with Interim Executive Director and a copy is provided.the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 14-AS-20250113154240

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jul 11, 2025

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews and medical records, on 10/16/24 a CT scan was conducted for R1 on his/her left hip for a possible fall. Medical documentation indicated that the CT scan showed that R1 had an acute non-displaced fracture through the base of the left superior pubic ramus and through the mid left inferior pubic ramus which poses an immediate health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: Licensee/administrator shall conduct an in-service training regarding fall risk and ensuring changes in resident's condition are documented. In addition, training shall also include, fall prevention planning when residents are at low to high fall risk. Civil penalty in the amount of $500.00 is being assessed today as Resident 1 (R1) sustained unexplained fracture while in care. A repeat civil penalty of $500 was issued today due to the same violation being cited on 5/27/25. Due to immediate civil penatly of $500 being cited and repeat civil penalty of $500 being cited, total civil penalty being issued today is $1000.00

Type of visit: Case Management - Incident

On June 18, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to an incident that occurred on 5/31/25. LPA met with Administrator, Siobhan Surraco and explained the purpose of the visit. The Licensee reported on 5/31/25, the med-tech went to Resident 1's (R1's) room around 7:45pm and R1 reported to the med-tech that he/she took over seven days of medication at one time. R1 told to the med-tech that he/she wanted to hurt himself/herself because he/she was feeling depressed. According to the Licensee, R1 resides in the assisted living community and manages his/her own medications. 911 was immediately called and all required parties were notified. R1 was admitted at the hospital for psychiatric evaluation. During the visit today, LPA interviewed the Administrator, Health Services Director, and Resident Care Coordinator, and reviewed R1's file. R1 was admitted to the facility on 5/21/25 and based on the physician's report dated 5/21/25, R1 was able to manage his/her own prescription and PRN medications and did not show any signs of suicidal ideations. Based on the new physician's report dated 6/11/25 (after incident occurred), R1 has a diagnosis of early onset of Alzheimer's dementia, and is unable to manage his/her own medications. According to staff interviewed, R1 returned back to the community on 6/16/25 and a 1:1 caregiver was implemented throughout the day for 72 hours. Facility staff are conducting status checks. R1 is seeing a psychiatrist and going to behavioral therapy session 5 days a week. Facility is now managing R1's medications and a new reassessment has been conducted. No citations are issued today. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Jun 18, 2025

Type of visit: Case Management - Incident

On May 27, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on a case management visit that was conducted on 5/15/25. LPA met with Resident Services Director, Edward DeWitt and explained the purpose of the visit. On 5/15/25, LPA followed up on an incident that occurred on 5/1/25 at 2pm, where care staff reported that they heard the patio door alarm sounding and noticed that Resident 1 (R1) had exited the secured memory care unit without staff supervision. R1 was found a half a block away from the facility. During the visit conducted on 5/15/25, LPA reviewed R1's file, interviewed staff and toured the facility. Based on the file reviewed, LPA observed R1's physician's report to indicate R1 has MCI, however the physician crossed out the section where it indicated whether R1 can leave the facility unassisted or not. Staff interviewed were not clear if R1 can leave unassisted. In addition, staff interviewed indicated R1 left the facility through the memory care outdoor terrace door to the outdoor terrace area and walked to the side of the terrace then left through the second door to get outside the facility. Based on observations, both door were observed to be delayed egress doors and both doors were observed to be in working condition. Staff interviewed were unsure how R1 left without staff noticing but believe that R1 left the facility unassisted during shift change. On 5/22/25, the facility received confirmation from R1's responsible party that R1's physician diagnosed R1 with dementia on 3/5/25. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D due to R1 leaving a secured unit unattended. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with the Resident Services Director and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, May 27, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: May 28, 2025

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c). This regulation is not met as evidenced by: Based on interviews, observations and record reviews, R1 has dementia and left the unit/facility unattended and was found a block away from the facility which poses an immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, May 27, 2025

Plan of correction: Licensee/administrator will develop a plan to ensure residents will not leave the memory care unit unattended and the plan shall include staff training.

Type of visit: Case Management - Incident

On May 15, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that occurred on 5/1/25. LPA met with Administrator, Siobhan Surraco and explained the purpose of the visit. The Licensee reported on 5/1/25 at 2pm, care staff reported that they heard the patio door alarm sounding and noticed that Resident 1 (R1) had exited the secured memory care unit without staff supervision. Staff reported they last saw R1 at around 1:50pm in his/her room. R1 was found a half a block away at around 2:10pm with no injuries and unharmed. During the visit, LPA toured the memory care unit, reviewed R1's file, interviewed the administrator and the Resident Care Director (RCD). Based on medical records dated 11/2024, R1 has mild cognitive impairment (MCI). R1 does not have a history of wandering behaviors based on file reviewed. According to the Administrator, R1 resides at the memory care unit with his/her significant other. R1 left the facility through the memory care outdoor terrace door to the outdoor terrace area and walked to the side of the terrace then left through the second door to get outside the facility. Both doors were observed to be delayed egress doors. Both delayed egress doors were observed to be in functioning condition. According to the administrator and RCD, they are unsure how R1 left without staff noticing but believe that R1 left the facility unassisted during shift change. LPA was unable to interview staff who were present during the incident as they were not present at the facility. Further investigation is required. No citations are issued during the visit. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, May 15, 2025

Type of visit: Required - 1 Year

On October 31, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrator, Siobhan Surraco and explained the purpose of the visit. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a 3 story facility with Memory Care on the first and half of the second floor and Assisted Living on the other half of the second floor and third floor. LPA toured the facility including but not limited to a random sample of resident rooms on each floor, common areas, and kitchen area. LPA observed some residents doing activities with staff or watching television. A comfortable temperature is maintained in the facility and lighting is sufficient for comfort. Hot water temperature measured between 111-119 degrees F throughout the facility. Overall facility was in clean, odor-free and free from any tripping hazards. Resident rooms and bathrooms observed had all required furnishings, and grab bars and built-in non-skid mats in each bathroom. LPA toured kitchen and observed 2 days for perishables and and 7 days non-perishable. Medications, sharps and chemicals were locked and inaccessible to residents. Emergency drill are being conducted and logged every 3 months. Carbon monoxide monitors are working properly. First aid kits were observed present and complete. Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. The following documents are requested to be submitted to CCL by 11/7/24: -LIC308 Designation of Administrative Responsibility -LIC610E Emergency Disaster Plan -LIC500 Personnel Report No deficiencies are cited at this time. Report is reviewed with Administrator and copy is provided.the state’s words, verbatim · CDSS document, Oct 31, 2024

Allegation investigated: - Staff lock residents in their room - Residents eloped from the facility - Staff did not report unusual incident to resident's representative - Staff did not feed resident in care - Staff did not dress resident in care - Staff not provide resident with hygiene needs

On 05/10/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver the findings regarding the allegations received. LPA met with administrator Siobhan Surraco and explained the purpose of today's visit. During the investigation LPA conducted interviews and made observations. Interviews with staff, and a tour of resident rooms, show that the rooms are able to be unlocked from the inside by just turning the door handle. The locking mechanism is on the inside and can be unlocked from the outside via room key. LPA and administrator was able to unlock the residents room with a key as a demonstration and the resident inside locked the door themself after it was unlocked and announced entrance to the room. Interviews with staff do contradict with the allegation that residents are being locked in their rooms intentionally. Continued on next page... Unsubstantiated Page 2 - LIC9099C Regarding elopements from the facility, LPA cannot determine if this took place based on information received regarding these alleged incidents. There is not enough information and support to show that residents in fact eloped based on staff, video, and family interviews conducted. At the time of the alleged elopements those original staff that were in place, including memory care directors, are no longer present and cannot be contacted. No elopements were reported to management in order to report an incident to the Department. LPA cannot determine if incident reporting took place for the elopements in question. Regarding staff not feeding, dressing, or providing hygiene needs for residents. LPA conducted interviews and made facility observations. Interviews with staff show that the resident in question regarding not feeding or dressing a resident contradict with complainant information and interviews conducted. It was indicated by staff that the residents have the freedom of choice of getting dressed when getting ready in the morning. The resident in question refused to get ready in the morning and staff can not force a resident to change or do something they do not want to do as it will be against their personal rights. For the same resident LPA cannot determine if the was fed on time as the resident was refusing morning care that morning and staff were turned away by the resident and staff intended on returning to the resident to follow up with morning care and feeding. Regarding staff not providing hygiene needs, LPA toured resident rooms that are occupied and observed toilet paper in place. The resident in question is no longer at the facility at the time of investigation to observe if toilet paper was present. Staff interviewed indicate that if there was no toilet paper it would be provided if needed. Staff do replenish toilet paper everyday and when needed. Based on interviews, observations, and other items reviewed, LPA cannot determine if these allegations took place. These allegations are unsubstantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report is reviewed with the administrator Siobahn Surraco and a copy of the report is provided.the state’s words, verbatim · CDSS document, May 10, 2024 · control 14-AS-20230807085356

Allegation investigated: - Staff spoke to resident in an inappropriate manner - Staff did not ensure faucet was delivering warm water during showers - Staff threatened resident - Facility failed to report an incident to licensing

On 02/21/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannouced complaint investigation visit in order to deliver findings regarding the allegations received. LPA met with administrator Siobhan Surraco and explained the purpose of today's visit. During the investigation LPA conducted interviews and made observations. Interviews with residents and staff contradict one another. LPA cannot prove or disprove the statements made to the resident were said in the manner reported as part of this complaint. LPA observed the shower area of resident and confirmed that warm water is being delivered to the shower. The incident was investigated by the department and the facility itself but no conclusions or perponderance of evidence was found. These allegations are unsubstantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 21, 2024 · control 14-AS-20230809112435

Allegation investigated: - Staff are not responding to resident's representative's requests for communication in a timely manner

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the above allegation. LPA met with Interim executive director Eugenia Smith and explained the purpose of today's visit. During the course of the investigation LPA conducted multiple interviews and reviewed protocols with previous executive director Meghan Leone and interim executive director Jessica Pryor. According to Meghan, she began working at the facility on Monday July 24th, 2023. A COVID outbreak in memory care began the week prior to her starting work at the facility close to the weekend before the Monday she started. There was not an administrator in place to access the information of the affected residents family members to alert them in mass. She started on July 24, 2023 and worked on informing and reporting the COVID outbreak to families and the Department that same week. The Department did receive COVID incident reports from Meghan. Meghan provided LPA a copy of this email via print out of her reporting to family members as well. Continued on next page... Unsubstantiated Page 2 - LIC9099 Meghan indicated that responsible parties emails were used that are on file with the facility, and if there was any issue of a particular family member not being notified, it was possibly due to them not being the responsible party contact so they were not emailed as part of the responsible party group. According to interim executive director Jessica Pryor, she was in place in the facility from Jun30, 2023 up until July 17,or 18, 2023. She stated that she held at least two open discussions and meetings with family members and responsible parties of both memory care and assisted living. She says posts were made through out the facility and says that responsible parties were contacted via email as well. She says there was an open house meeting that took place on July 4, 2023 and another introduction/Q&A the following week after that inviting family members to attend as part of the transition process as the facility transitioned from Sunrise of Redwood City to Oakmont of Redwood City. She provided LPA with email support to show that an email was sent to family members on June 9, 2023 from the previous company Sunrise, and an additional email and posting that was provided to family members around June 30, 2023 in the facility and by email. Due to the items observed and data collected these allegations are unsubstantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report if reviewed with interim executive director Jessica Pryor.the state’s words, verbatim · CDSS document, Jan 10, 2024 · control 14-AS-20230725115745

Allegation investigated: - Resident sustained injuries while in care - Staff are not fully trained

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the above allegation. LPA met with Interim executive director Jessica Pryor and explained purpose of today's visit. During the course of the investigation LPA conducted multiple interviews with residents and staff. LPA also reviewed training documents as well. LPA concluded that based off the records of staff training, staff are being trained regularly thorugh out the year and using their training database and shadowing hours. LPA observed names from both assisted living and memory care staff attended these regular training. As for resident sustaining injuries while in care, through records review and interviews it was found that the resident in question did have falls due to physical limitations and not from other reasons besides falls that occurred. These falls are documented. These allegations are unsbustantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 10, 2024 · control 14-AS-20230803111423

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 1/10/2024 at 1230pm, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - other visit in order to deliver an amended complaint report. LPA met with Interim executive director Jessica Pryor and explained the purpose of today's visit. LPA delivered amended findings for complaint #14-AS-20231205135135. LPA is delivering the report as Public as it was marked as Confidential in error. Report is reviewed with interim executive director Jessica Pryor.the state’s words, verbatim · CDSS document, Jan 10, 2024

Allegation investigated: - Staff did not assist resident to and from restroom

On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the allegation received. LPA met with business office director Ana Gobaleza and explained the purpose of today's visit. During the course of the investigation, LPA conducted interviews, made facility observations, and reviewed documents. Per interviews with staff, they did not witness the situation described per details received. Staff recall being present but did not see the situation. Staff indicated that the resident did not ask for assistance. The location of the bathroom where this took place was not in sight of the staff who was providing an activity with other residents in the memory care's living room area. The bathroom is around the corner out of the line of sight from the nearest staff person at the time this took place. The resident's room is also located across the hall from where the bathroom is. The resident does require assistance to the bathroom but according to staff they were not alerted to assist the resident to the restroom, but instead the resident went to the restsroom on their own without assistance being called for. This allegation is unsubstantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report is reviewed with Ana Gobeleza. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 14, 2023 · control 14-AS-20230919091925

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: - Staff are not following infection control requirements.

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the above allegation. LPA met with Business Office Director Ana Gobeleza and explained purpose of today's visit. During the course of the investigation LPA conducted multiple interviews and reviewed protocols with previous administrator Meghan Leone. LPA discovered that there was not enough COVID test kits on hand during an outbreak in memory care. Additionally, isolation procedures, social distancing, appropriate signs, hand sanitizer, gowns, and masking requirements were not being fully adhered to during the outbreak. Residents were congregating despite of COVID status and there was a lack of PPE being utilized to help mitigate the spread of COVID. This allegation is substantiated. Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D. Report is reviewed with Ana Gobeleza. Appeal rights are provided. Substantiatedthe state’s words, verbatim · CDSS document, Dec 14, 2023 · control 14-AS-20230725115745

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 15, 2023

87468.1 Personal Rights of Residents in All Facilities - (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This regulations has not been met as evidenced by: Per interviews conducted the facility did not have enough COVID test kits to test residents with symptoms of COVID in memory care. isolation procedures, social distancing, appropriate signs, hand sanitizer, gowns, and masking requirements were not being fully adhered to during the outbreak. The facility did not provide a safe and healthful accomodation for residents.the state’s words, verbatim · CDSS document, Dec 14, 2023

Plan of correction: The licensee shall comply with the regualtion stated herewithin. The licensee/facility shall revisit infection control protocols and resubmit to licensing. A written statement of correnction and invection control plan of such shall be recieved by the POC date.

Allegation investigated: - Staff mismanaged residents' medication - Untrained staff

*** This is an amended document marking the report as public *** On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the above allegation. LPA met with interim executive director Jessica Pryor and explained purpose of today's visit. During the course of the investigation LPA made observations of the facility medication administration practices, med cart oraganization, reviewed resident medication administration recording process, and reviewed training records. LPA observed that all observed items are in place. LPA asked two med techs to demonstrate their medication handling practices. Medication training for med techs are reviewed as current. These allegations are unsubstantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report is reviewed with Jessica Pryor. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 14, 2023 · control 14-AS-20231205135135

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Post Licensing

On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced post licensing inspection visit. LPA met with interim administrator Eugenia Smith and explained the purpose of today's visit. LPA was allowed entry into the facility and signed in. This is a multi level facility and a memory care building attached. Annual Fees are current upon review. The physical plant was toured inside and outside to ensure the safety of the residents. Patio area outside of memory care building is observed. Fencing and security doors are in good condition and in place. LPA observed the facility kitchen which is clean, in order, and the observed appliances are in good repair. Knives are stored in the kitchen which is not accessible to residents. Cleaning solutions are also locked in multiple janitor closets through out the facility. Perishable and non-perishable food items are observed as in place. LPA observed the medications as in place and locked in med-carts and in med-rooms. First aid kits are observed as complete and placed through out facility including the kitchen. LPA observed that the facility is equipped with full sprinkler system, fire extinguishers are placed through out the facility inspected in October 2023, smoke detectors/carbon monoxide detectors are observed in place, and central heating system is operable. Facility ambient temperature is comfortable for residents and visitors. PPE and additional food supplies are observed as in place. Main laundry room is observed as operational and laundry rooms for use by residents if they choose to wash their own laundry are observed as safe and operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 108F in resident rooms in assisted living and memory care. LPA observed several resident rooms at random and all rooms appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. COVID PPE and resident incontinence supplies are observed in place. The facility does not handle resident monies. Staff and resident files are reviewed and observed as current. The facility is in the process of hiring a permanent administrator. Report is reviewed with Eugenia. No citations issued.the state’s words, verbatim · CDSS document, Dec 14, 2023

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with interim administrator Eugenia Smith and explained the purpose of today's visit. LPA was allowed entry into the facility and signed in. This is a multi level facility and a memory care building attached. Annual Fees are current upon review. The physical plant was toured inside and outside to ensure the safety of the residents. Patio area outside of memory care building is observed. Fencing and security doors are in good condition and in place. LPA observed the facility kitchen which is clean, in order, and the observed appliances are in good repair. Knives are stored in the kitchen which is not accessible to residents. Cleaning solutions are also locked in multiple janitor closets through out the facility. Perishable and non-perishable food items are observed as in place. LPA observed the medications as in place and locked in med-carts and in med-rooms. First aid kits are observed as complete and placed through out facility including the kitchen. LPA observed that the facility is equipped with full sprinkler system, fire extinguishers are placed through out the facility inspected in October 2023, smoke detectors/carbon monoxide detectors are observed in place, and central heating system is operable. Facility ambient temperature is comfortable for residents and visitors. PPE and additional food supplies are observed as in place. Main laundry room is observed as operational and laundry rooms for use by residents if they choose to wash their own laundry are observed as safe and operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 108F in resident rooms in assisted living and memory care. LPA observed several resident rooms at random and all rooms appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. COVID PPE and resident incontinence supplies are observed in place. The facility does not handle resident monies. Staff and resident files are reviewed and observed as current. The facility is in the process of hiring a permanent administrator. Report is reviewed with Eugenia. No citations issued.the state’s words, verbatim · CDSS document, Dec 14, 2023