Oakmont of Riverpark

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced Case Management – Incident visit at approx. 9:00 a.m., LPA was greeted by front door receptionist and explained the reason for the visit. The LPA met with Executive Director (ED) Erik Bleitz and the reason for the visit was explained. Entrance interview conducted. The Department received a self reported incident report and a joint report of suspect dependent adult / elder abuse (SOC 341) regarding Resident #1 (R1) and Staff #1 (S1) on 07/22/2026 regarding an incident that occurred on 07/19/2026. During today’s visit starting at 9:23 a.m. and throughout the visit the LPA and ED conducted a physical plant tour to ensure there are no immediate health and safety concerns, conducted in-person interviews with the Executive Director (ED), Health Service Director (HSD), Memory Care Director (MCD), R1, S1, telephonic interviews with two (2) staff, Power of Attorney (POA) for R1, watched video footage of the incident, and a file and record review for R1 and S1 and obtained copies of pertinent documents relevant to the incident. The LPA has determined that further investigation is required prior to issuing findings. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Jul 28, 2026

Allegation investigated: Staff caused injury to resident

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to investigate the above listed allegation. Upon arrival at approx.10 a.m. LPA was greeted by front door receptionist and explained the reason for the visit. The LPA met with Executive Director (ED) Erik Bleitz and the reason for the visit was explained. Entrance interview conducted. On 05/27/2026, the Department received a complaint regarding the following allegation, Staff caused injury to resident. On 05/28/2026 LPA Zabel Chochian conducted the initial 10-day visit LPA conducted a physical plant tour, interviewed four (4) residents beginning at approximately 2:15 p.m. and three (3) staff from approximately 2:45 p.m.-3:15 p.m. On 06/01/2026 LPA Mosley conducted a subsequent visit Starting at 11:09 a.m. and throughout the visit LPA conducted a physical plant tour, interviewed the ED at the time, Staff #1 (S1), Resident #1 (R1) attempted to contact Staff #2 (S2) telephonically, conducted a file and record review for R1 and S1, and obtained copies of pertinent documents relevant to the investigation. On 06/02/26 at 2:45 p.m. conducted a telephonic interview with S2. Report continued on LIC 9099-C PAGE 2... Substantiated (PAGE 2) Report continued from LIC 9099... During today's visit LPA and ED briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. LPA obtained copies of pertinent documents relevant to the investigation. On the allegation, Staff caused injury to resident, it is the concern of the Reporting Party (RP) that S1 caused an injury / skin tear to R1. To investigate this complaint, LPA conducted in person interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation. Interview with S1 revealed that on 05/23/26 at approximately 10:00 a.m., R1 came to the medication room requesting their medication, although they had already received their medication for the day. S1 informed R1 that their medication had already been administered and redirected R1 outside before continuing with their duties. However, R1 was persistent and returned multiple times. S1 stated this occurred approximately three times, with R1 repeatedly returning to the medication room requesting their medication, and S1 redirecting them each time. S1 reported that the med room door was slightly open and R1 was standing at the doorway. S1 stated, “R1 is persistent and at times difficult to redirect.” During R1’s third return, R1 attempted to insert their key into the medication room door lock. S1 stated that they “pulled the lanyard, slightly scraping the resident and leaving a red mark; there was a tiny skin break and a small skin tear.” S1 further stated, “It was a tiny red mark; the skin was slightly broken.” S1 observed two tiny holes and provided first aid to R1. Interview with R1 revealed that due to cognitive decline, the R1 is unable to recall the incident. R1 states that they feel safe at the facility and have no concerns regarding the care that is being provided. R1 states that the staff treat them well. Based on information gathered during the course of the investigation, and interviews there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Staff caused injury to resident, is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties. The Executive Director (ED) departed at 4:23 p.m. and designated the Business Office Director (BOD) to sign the report on their behalf. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 29-AS-20260527143402

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jul 18, 2026

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on staff interview the Licensee did not comply with the regulation above, when staff #1 caused injury to Resident #1 including a skin tear which is an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2026

Plan of correction: ED will submit the employees (S1) statement of understanding of residents personal rights by POC due date 07/17/2026. ED will have S1 conduct training on resident rights, dignity and handing residents and redirection by POC due date 07/31/2026 and send proof to LPA.

Allegation investigated: Staff did not properly supervise residents, resulting in multiple elopements Staff speak to residents in an inappropriate manner Staff did not provide proper supervision, resulting in a physical altercation between residents Staff did not provide adequate food service

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to investigate the above listed allegations. Upon arrival at approx.10 a.m. LPA was greeted by front door receptionist and explained the reason for the visit. The LPA met with Executive Director (ED) Erik Bleitz and the reason for the visit was explained. Entrance interview conducted. On 06/30/2026, the Department received a complaint regarding the following allegations, Staff did not properly supervise residents, resulting in multiple elopements, Staff speak to residents in an inappropriate manner, Staff did not provide proper supervision, resulting in an physical altercations between residents and Staff did not provide adequate food service. Report continued on LIC 9099-C PAGE 2... Unsubstantiated (PAGE 2) Report continued from LIC 9099...On 07/07/2026 starting at 10:53 a.m. and throughout the visit a physical plant tour was conducted, fifteen (15) in-person interviews, six (6) staff including the ED and nine (9) residents, a file and record review for Staff #1 (S1) and obtained electronic copies of pertinent documents relevant to the investigation. During today's visit LPA and ED briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. Starting at 10:26 a.m. and throughout the visit LPA conducted five (5) in-person interviews, three (3) staff and two (2) residents, attempted (1) resident interview, file and record review for Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), staff file review and obtained copies of pertinent documents relevant to the investigation. On the allegations, Staff did not properly supervise residents, resulting in multiple elopements, it is the concern of the Reporting Party (RP) that the facility staff have failed to conduct door checks and supervise residents resulting in multiple elopements. To investigate this complaint, LPA conducted in person interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation. Staff interviews revealed that the facility has not had any recent elopements; however, staff reported two (2) attempted elopements. Staff stated that in both incidents, the residents were supervised at all times. The first attempted elopement involved R1 in the assisted living department. R1 exited through the front door and was immediately followed by the concierge and an additional staff member. Staff were able to redirect R1 back into the community without incident. The second attempted elopement involved R2 and R3 in the memory care unit. Both residents exited when a family was entering the facility. Staff #2 (S2) observed the residents exiting and verbally alerted other care staff, as S2 did not have a walkie-talkie at the time. Staff #3 (S3) and Staff #4 (S4) responded and followed R2 and R3. Staff reported that the residents proceeded down the hallway, down the stairs, and exited through the side door; however, staff maintained visual supervision throughout. Additional staff exited the building through other doors to assist. Once R2 and R3 reached the parking lot, staff were able to redirect both residents safely back into the community. Staff reported that during both incidents, all residents involved remained safe and under staff supervision. LPA attempted to interview R1 at 12:11 p.m. and R1 refused to be interviewed. Report continued on LIC 9099-C PAGE 3... (PAGE 3) Report continued from LIC 9099-C PAGE 2... Interview with R2 revealed that due to cognitive decline, R2 was unable to recall the incident. R2 stated, “It’s hard to leave, I have tried,” and when asked further, R2 stated, “That’s the rules.” R2 also reported that they “have not left the community by themselves or with anyone else.” Interview with R3 revealed that due to cognitive decline, R3 was unable to recall the incident. R3 stated that they “have not left the community on their own or with anyone else.” R3 also reported that they have attempted to leave; however, they understand they are not permitted to leave unaccompanied. Random resident interviews indicated that residents were not aware of any individuals exiting the facility unsafely. Residents reported that staff consistently monitor the doors for safety and stated that they feel staff are actively supervising and attentive to their needs. Record review revealed that R1, R2, and R3 each have a diagnosis of Major Neurocognitive Disorder (NCD) documented on their physician reports. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff did not properly supervise residents, resulting in multiple elopements is deemed unsubstantiated at this time. On the allegation, Staff speak to residents in an inappropriate manner, it is the concern of the Reporting Party (RP) that S1 speaks rudely to residents and has slammed the door in their faces’. To investigate this complaint, LPA conducted in person interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation. Assisted Living resident interviews indicated that residents have not been spoken to in an inappropriate manner by any staff. Residents did not report any concerns regarding S1 and stated they have never been spoken to in an inappropriate manner by S1. Memory Care resident interviews indicated that residents enjoy the care provided by staff and reported no concerns regarding any staff members. Due to cognitive decline, memory care residents were unable to identify S1. Report continued on LIC 9099-C PAGE 4... (PAGE 4) Report continued from LIC 9099-C PAGE 3...Staff interviews revealed no concerns regarding S1 or S1’s job performance. Staff described S1 as “really nice” and reported that they have not witnessed S1 speaking to residents in a rude manner or slamming a door in a resident’s face. An interview with the Memory Care Director (MCD), S1’s direct supervisor, revealed that S1 has not received any disciplinary action and there have been no complaints regarding S1. MCD stated they have never observed or heard S1 speak to residents in a rude manner, and no staff or residents have voiced concerns about S1’s behavior. During an interview with S1, S1 stated that they believe they have positive interactions with all residents. S1 reported that they respect and uphold residents’ personal rights and have never yelled at a resident, spoken to a resident in a rude manner, or slammed a door in a resident’s face. S1 stated they treat all residents with dignity and respect. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff speak to residents in an inappropriate manner is deemed unsubstantiated at this time. On the allegation, Staff did not provide proper supervision, resulting in a physical altercation between residents, it is the concern of the Reporting Party (RP) that residents engage in physical altercations and have happened numerous times. To investigate this complaint, LPA conducted in person interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation. Staff interviews revealed that, to their knowledge, there have not been any physical altercations resulting from poor supervision. Staff reported one recent incident on 07/04/2026 in which a resident became agitated and pushed another resident, then became physically aggressive toward staff. The resident was subsequently transported to the hospital for evaluation. Staff stated that they were in close proximity during the interaction and intervened immediately. Staff further reported that they have not witnessed or heard of any other physical altercations within the community. Resident interviews indicated that they have not heard of any physical altercations occurring in the community. Residents described staff as consistently present and stated that staff would not allow such incidents to occur. Residents reported that they feel safe within the community. Report continued on LIC 9099-C PAGE 5... (PAGE 5) Report continued from LIC 9099-C PAGE 4... Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff did not provide proper supervision, resulting in a physical altercation between residents is deemed unsubstantiated at this time. On the allegations, Staff did not provide adequate food service, it is the concern of the Reporting Party (RP) that facility staff leaves residents in bed and skips their meals. To investigate this complaint, LPA conducted in person interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation. Staff interviews revealed that staff make multiple attempts when a resident refuses a meal. Staff reported that residents are typically asked up to three times, after which another staff member will attempt to offer the meal. If the resident continues to refuse, staff contact the resident’s family, which staff stated is usually effective. Staff described ordering the resident’s usual meal and leaving the tray set up for accessibility. Staff stated they make every effort to ensure residents eat and do not skip a resident’s meal unless the resident has clearly refused after multiple attempts and alternative options have been offered. Staff reported they have never intentionally skipped a resident’s meal. Resident interviews indicated that the facility provides adequate food services, offering a variety of options. Residents may dine in the dining room or request a tray in their room. Residents reported that they have never been forced to skip a meal by staff. Record review, including but not limited to meal rosters, revealed that during the period of 06/30/26 through 07/06/26, there was only one meal refusal recorded, and all breakfast meals were served. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff did not provide adequate food service is deemed unsubstantiated at this time. The Executive Director (ED) departed at 4:23 p.m. and designated the Business Office Director (BOD) to sign the report on their behalf. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 29-AS-20260630093408

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. The LPA met with Executive Director Kailey Vanderwall and Erik Bleitz explained the reason for the visit. Entrance interview conducted. The reason for today's inspection is to follow up on a self-reported death report received on 03/11/2025. The report pertains to the death of Resident #1 (R1). It was reported R1 was sent to the hospital on February 23th due to a fall and passed away on March 8th at the hospital. Due to interviews conducted and record review, no deficiencies cited at this time regarding the death of R1. Exit interview conducted. A copy of the report was issued to the Executive Director.the state’s words, verbatim · CDSS document, Jun 2, 2026

Type of visit: Case Management - Other

Licensing Program Analyst, Zabel Chochian arrived on 05/28/2026 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. The LPA met with Executive Director Kailey Vanderwall. On February 9, 2023, the Department concluded a complaint investigation regarding the following allegation: Facility staff failed to provide an appropriate level of supervision which resulted in resident falling and sustaining a fracture. The licensee was cited for California Code of Regulations (CCR) 87464(f)(1) Basic Services. At the time of the complaint visit on February 9, 2023, an immediate civil penalty of $500 was issued. Due to the fact that this was a repeated violation, an additional $500 was levied. The Licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). 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 the facility not providing adequate care and supervision for the resident (R1). R1 fell and sustained a fracture of the right humerus and bruise of the right eye, which required hospitalization. Today, 05/28/2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department determines constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on February 9, 2023, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Executive Director, Kailey Vanderwall and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, May 28, 2026

Allegation investigated: Administrator is not at the facility for a sufficient amount of time Administrator did not ensure the facility had a designated substitute in their absence

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced initial 10-day complaint visit to investigate the above listed allegations. Upon arrival at approx.10:15 a.m. LPA was greeted by front door receptionist and explained the reason for the visit. The LPA met with Executive Director (ED) Kailey Vanderwall and reason for the visit was explained. Entrance interview conducted. On 03/04/2026, the Department received a complaint regarding the following allegations, Administrator is not at the facility for a sufficient amount of time and Administrator did not ensure the facility had a designated substitute in their absence. During today's visit LPA and staff briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. Starting at 10:25 a.m. and throughout the visit LPA conducted nine (9) in-person staff interviews including the Administrator / ED, a file and record review for the Administrator/ ED, facility record review and obtained copies of pertinent documents relevant to the investigation. Report continued on LIC 9099-C PAGE 2... Unsubstantiated (PAGE 2) Report continued from LIC 9099... On the allegations, Administrator is not at the facility for a sufficient amount of time and Administrator did not ensure the facility had a designated substitute in their absence it is the concern of the Reporting Party (RP) that the ED arrives between approximately 11:00 a.m.–12:00 p.m. and leaves between 3:00 p.m.–4:00 p.m. impacting timely decision-making regarding resident care while leaving no one in charge in their absence. To investigate this complaint, LPA conducted in person interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation. Staff interviews revealed that the ED is on site daily, Monday – Friday with the start time typically ranging from 8:00 a.m. to 9:00 a.m., and usually not past 9:00 a.m. due to a standing 9:30 a.m. daily Director’s meeting. The exact time may fluctuate depending on community needs, events, or coverage of NOC-shift schedules. Administrative staff, including the ED, make themselves available to residents and staff. If one director is not available, another director is present to address concerns. The ED is regularly on site and remains available after hours. During NOC shift hours, depending on the urgency of the issue, the Health Services Director (HSD) is contacted and “responds promptly”. The ED may also be contacted by staff or any of the other directors. It was noted that “There is always a director available either in person, by phone, or by text”. When the ED is not on site, a designee is always assigned. Typically, the Business Office Director serves as the designee; however, since the Business Office Director is currently new to the role, the HSD has been serving in that capacity. Residents are notified weekly via email and a hard-copy notice placed in their mailbox, which includes ED updates, community updates, and information on the designated manager on duty for specific days. Record review revealed that the ED is scheduled Monday through Friday from 8:00 a.m. to 6:00 p.m. During today’s visit, LPA obtained copies of the facility designee forms listing the Health Services Director, Maintenance Director, Memory Care Director, and Business Office Director. Although the allegations may have happened or are valid, there is insufficient evidence to prove the alleged violations did or did not occur. Therefore, the allegations of Administrator is not at the facility for a sufficient amount of time and Administrator did not ensure the facility had a designated substitute in their absence are deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Mar 11, 2026 · control 29-AS-20260304120301

Allegation investigated: Staff did not issue a refund to the resident's authorized representative in a timely manner

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to investigate the above listed allegation. The purpose of this visit is to deliver findings for the above listed allegation. Upon arrival at approx. 10:25 a.m. LPA was greeted by front door receptionist and explained the reason for the visit. The LPA met with Kailey Vanderwall, Executive Director (ED) and Ketmany Nantavong Health Servies Director and the reason for the visit was explained. Entrance interview conducted. On 12/18/2025, the Department received a complaint regarding the following allegation, Staff did not issue a refund to the resident's authorized representative in a timely manner. On 12/22/2025 starting at 10:55 a.m. LPA conducted three (3) in-person staff interviews, a file and record review for Resident #1 (R1), conducted a telephonic interview with the Authorized Representative (AR) for R1 and obtained copies of pertinent documents relevant to the investigation. On 01/13/2026 at 1:33 p.m., 01/20/2026 at 1:18 p.m. and 01/20/2026 at 3:06 p.m. attempted to conduct a telephonic interview with AR. On 01/20/2026 at 11:33 a.m. conducted a telephonic interview with the ED and at 2:14 p.m. conducted a telephonic interview with AR. Report continued on LIC 9099-C PAGE 2... Substantiated (PAGE 2) Report continued from LIC 9099... During today's visit LPA and ED briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. On the allegation, Staff did not issue a refund to the resident's authorized representative in a timely manner, it is the concern of the Reporting Party (RP) that R1’s AR did not receive the refund check within the required 15 days after the room was vacated. To investigate this complaint, LPA conducted in person interviews, telephonic interviews, file and record review and obtained copies of pertinent documentation relevant to the investigation. Interviews with AR revealed that R1’s belongings were fully vacated on 10/17/2025. As of 12/22/2025, AR reported that they had not received the refund check. It was noted that AR and the ED corresponded via email regarding the status of the refund; however, AR stated that they received the same explanation for the past month without resolution. AR expressed dissatisfaction with the length of time taken to resolve the matter. Additionally, AR noted that the facility handbook states refunds will be issued within 30 days, while the Health and Safety Code requires refunds to be issued within 15 days. Neither timeline was met. On 01/20/2026 at 2:14 p.m. AR stated they received the refund check on 12/27/2025. Interviews with the ED revealed that R1 passed away on 10/07/2025 and the room was fully vacated on 10/17/2025. During the move-out walk through, extensive damage beyond normal wear and tear was discovered. The repairs included damage to the pony wall, refrigerator, walls throughout the apartment, and counter tops, which the AR acknowledged and confirmed awareness of. The ED explained that the repairs required a third-party vendor, contributing to the delay in issuing the refund. They stated that they did not want to issue a refund prematurely and risk additional charges surfacing later. An estimated time frame of 30–60 days was provided to AR. The ED clarified that families are responsible for costs associated with damages beyond normal wear and tear, and refunds are only issued once all charges are finalized. Additionally, the ED noted that checks are not processed in-house, which further contributed to the delay. On 12/15/2025, the ED emailed AR confirming that all repairs had been completed and they were waiting for the refund check. The ED acknowledged the delay and noted the “gray area” between facility contractual refund timelines and regulatory requirements, emphasizing the importance of consulting their legal department to ensure compliance moving forward. Report continued on LIC 9099-C PAGE 3... (PAGE 3) Report continued from LIC 9099-C page 2... On 01/20/2026, the ED stated that the refund was mailed and delivered to AR on 12/27/2025. They added that this was a very specific case and confirmed that they have consulted with their legal department to ensure compliance with refund timelines in the future. Records review revealed that R1 moved into the facility on 04/04/2021 and passed away on 10/07/2025. Email correspondence between the Executive Director (ED) and AR indicated that on 10/16/2025, AR confirmed the apartment would be vacated on 10/17/2025. On 10/27/2025, ED noted that repairs and cleaning were ongoing and that AR would be informed once completed. On 12/15/2025, ED communicated that they wanted to ensure everything was accurate and completed before following up, and confirmed that all damage had been repaired. AR responded expressing dissatisfaction with the timeframe, citing the facility handbook policy of 30 days and the regulatory standard of 15 days. On 12/18/2025, ED stated they were awaiting the refund check, as checks are not processed in-house, and assured AR they would provide updates accordingly. Based on information gathered during the course of the investigation, and interviews there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Staff did not issue a refund to the resident's authorized representative in a timely manner is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 26, 2026 · control 29-AS-20251218080708

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: Jan 30, 2026

§1569.652 Termination of admission agreement upon death of resident... and refunds (c) A refund of any fees paid in advance...shall be issued...to the resident’s estate, within 15 days after the personal property is removed.This requirement is not met as evidenced by Based on interviews and record review, the facility did not comply with the above cited section, as R1 passed away on 10/07/25, belongings were removed on 10/17/25 and check was received on 12/27/25, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 26, 2026

Plan of correction: On 1/20/26, AR of R1 confirmed they had received the refund from the facility and the ED also agreed to review section cited and submit a statement of understanding and plan to ensure future compliance and send to LPA by 01/30/2026. Additionally, the ED stated they have informed their legal department to ensure future compliance.

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

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a Case Management - Legal/Non-compliance visit at 10:25 a.m. The purpose of today’s visit was to ensure the facility was maintaining substantial compliance as discussed in the Non-Compliance Conference that took place on 06/25/2025. As a result of the non-compliance conference, the Licensee is placed on frequent monitoring for a period of one (1) year. The LPA met with Kailey Vanderwall, Executive Director (ED) and Ketmany Nantavong Health Servies Director and explained the reason for the visit. During today’s visit, LPA focused on the physical plant / surrounding grounds. The LPA and ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: The facility is a double-story residence that consists of a memory care unit, and an assisted living unit. LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced on 02/27/2025. LPA observed all the required postings in the Activity Room near the entrance area, and throughout the facility. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Activities observed on both units. Common Areas: These included the beauty salon, library, activity room, theater, fitness center, bistro, and dining areas in assisted living and memory care units. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Fireplaces were properly screened. LPA observed designated storage / utility rooms with emergency food and water. Report Continued on LIC 809-C PAGE 2... (PAGE 2) Report Continued from LIC 809-C... Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents in both, the memory care unit courtyard and the assisted living courtyard. Parking is available for residents and visitors. Bedrooms: There are eighty -six (86) total apartments in the facility, fifty-nine (59) assisted living of which ten (10) are open studios, twenty-three (23) are one bedrooms, fifteen (15) are two (2) bedrooms, and eleven (11) studios with a double occupancy in the two (2) bedrooms, one (1) bedrooms, and open studios with a one hundred and seven (107) capacity. There are twenty-seven (27) apartments in memory care of which twenty one (21) are studios and six (6) are one (1) bedrooms with a double occupancy in the open studios, and one (1) bedrooms with a capacity of thirty- three (33) with a total capacity of one hundred and forty (140) in all. They are approved for eight (8) bedridden residents, and have a hospice waiver for fifteen (15). LPA observed ten (10) randomly selected resident bedrooms, (105, 107, 201, 243, 240, 229, 110, 114, 125A, 125B) of which six (6) in assisted living and four (4) in memory care. All resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. All passageways were observed to be clear of obstructions. Restrooms: Resident restrooms appeared clean, sanitary and in operating condition with grab bars and to be equipped with a slip resistant surface / mat. The restrooms were sufficiently stocked with supplies and paper towels. Towels and washcloths are not shared among the rooms. The hot water temperature was measured and ranged between 105.3 - 110.0 degrees Fahrenheit all within the required range. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are available for residents in the dining area. Knives are stored and inaccessible to residents. Refrigerator and food pantry were checked for proper labels and expiration dates. Documents: Documents obtained during the visit include: Facility / Staff roster and a Resident roster. No citations issued. Exit interview conducted. Copy of report reviewed and provided.the state’s words, verbatim · CDSS document, Jan 26, 2026

Allegation investigated: Staff did not provide authorized representative a refund after resident passed away

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to investigate the above listed allegation. The purpose of this visit is to deliver findings for the above listed allegation. Upon arrival at approx. 10:15 a.m. LPA was greeted by front door receptionist and explained the reason for the visit. The LPA met with Executive Director (ED) Kailey Vanderwall and reason for the visit was explained. Entrance interview conducted. On 11/06/2025, the Department received a complaint regarding the following allegation, Staff did not provide authorized representative a refund after resident passed away. On 11/13/2025 starting at 10:43 a.m. LPA conducted three (3) in-person interviews with the ED, a caregiver and the Maintenance Director, at 11:02 a.m. conducted a file and record review for Resident #1 (R1), at 1:19 p.m. conducted a telephonic interview with the Authorized Representative (AR) for R1 and obtained copies of pertinent documentation relevant to the investigation. On 11/13/2025 at 2:01 p.m. and 5:40 p.m., electronic correspondence from AR was received via email containing pertinent documentation relevant to the investigation. On 11/18/2025 at 5:29 p.m. and on 11/20/2025 at 10:39 a.m. conducted telephonic interviews with Witness #1 (W1). Report continued on LIC 9099-C PAGE 2... Unsubstantiated (PAGE 2) Report continued from LIC 9099... During today's visit at 10:31 a.m. LPA and ED briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. On the allegation, Staff did not provide authorized representative a refund after resident passed away, it is the concern of the Reporting Party (RP) that R1’s AR did not receive a full and accurate refund of the community fee and rent once R1 passed away. To investigate this complaint, LPA conducted in person interviews, telephonic interviews, corresponded via email, file and record review and obtained copies of pertinent documentation relevant to the investigation. Interview with the ED revealed that R1 moved into the facility on 06/30/2025 and fully moved out of the community with all belongings removed on 10/05/2025. R1 expired on 09/07/2025. The community hosted R1’s celebration of life on 09/28/2025 in the Bar & Lounge where R1’s belongings still remained in the community. The family gradually removed R1’s belongs with a date of 10/05/2025 documented as the official move out date. R1’s belongings remained in the community from 06/30/2025 to 10/05/2025 a total of 97 days as documented by facility records. The community policy states that after the 90th day the community fee is non-refundable. The ED stated that the community strives to meet the needs of all residents and their families and acknowledges that this is a difficult time. As a courtesy to the family, the ED confirmed that they will honor the families proposed dates, which is not typical. The community fee refund will be re-calculated based on R1’s move-in date of June 30, 2025, through the expiration date of September 7, 2025, a total of 69 days. The community will issue a refund based on the initial fee of $6,000, minus a $500 assessment fee. The refund will reflect 40% of that amount, which is $2,200. Additionally, the community will honor the families proposed move out date of September 11th, 2025, as the end of rent date. The facility processed a one-time check dated 11/18/2025 in the amount of $10,359.24 reflecting the community fee adjustment to reflect 69 days, rent adjustment to reflect a move out date of 9/11/2025. Staff interviews revealed that R1 expired on 09/07/2025. R1’s belongings remained in the community after September 11th and were completely removed at the end of September or beginning of October, the exact date is unknown. R1 had a majority of their big furniture items moved around September 11th however small items remained in their apartment. Report continued on LIC 9099-C PAGE 3... (PAGE 3) Report continued from LIC 9099-C PAGE 2... R1 had a celebration of life at the community on 09/28/2025 and R1’s belongings were still in their apartment. R1’s family gradually removed R1’s belongings. Interviews with W1 revealed that AR hired their company to move R1’s belongings to a storage unit. The company moved R1’s belongings on 9/12/2025. The company typically moves large furniture items. The family was also taking things to their car at the same time. They are unsure if all belongings in the room were fully vacated on that day. Documents and Record review revealed that R1 moved into the community on 06/30/2025 and expired on 09/07/2025. R1 moved out of the community on 10/05/2025. R1 had their celebration of life at the community on 09/28/2025. Invoice dated 9/12/2025 indicated three (3) hours of service to move out R1's belongings. Documented conversation of 09/28/2025 indicated R1 still has items in their apartment. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff did not provide authorized representative a refund after resident passed away is deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Dec 5, 2025 · control 29-AS-20251106161820

Allegation investigated: Staff did not provide authorized representative a refund after resident passed away

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to investigate the above listed allegation. The purpose of this visit is to deliver findings for the above listed allegation. Upon arrival at approx. 10:15 a.m. LPA was greeted by front door receptionist and explained the reason for the visit. The LPA met with Executive Director (ED) Kailey Vanderwall and reason for the visit was explained. Entrance interview conducted. On 11/06/2025, the Department received a complaint regarding the following allegation, Staff did not provide authorized representative a refund after resident passed away. On 11/13/2025 starting at 10:43 a.m. LPA conducted three (3) in-person interviews with the ED, a caregiver and the Maintenance Director, at 11:02 a.m. conducted a file and record review for Resident #1 (R1), at 1:19 p.m. conducted a telephonic interview with the Authorized Representative (AR) for R1 and obtained copies of pertinent documentation relevant to the investigation. On 11/13/2025 at 2:01 p.m. and 5:40 p.m., electronic correspondence from AR was received via email containing pertinent documentation relevant to the investigation. On 11/18/2025 at 5:29 p.m. and on 11/20/2025 at 10:39 a.m. conducted telephonic interviews with Witness #1 (W1). Report continued on LIC 9099-C PAGE 2... Unsubstantiated (PAGE 2) Report continued from LIC 9099... During today's visit at 10:31 a.m. LPA and ED briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. On the allegation, Staff did not provide authorized representative a refund after resident passed away, it is the concern of the Reporting Party (RP) that R1’s AR did not receive a full and accurate refund of the community fee and rent once R1 passed away. To investigate this complaint, LPA conducted in person interviews, telephonic interviews, corresponded via email, file and record review and obtained copies of pertinent documentation relevant to the investigation. Interview with the ED revealed that R1 moved into the facility on 06/30/2025 and fully moved out of the community with all belongings removed on 10/05/2025. R1 expired on 09/07/2025. The community hosted R1’s celebration of life on 09/28/2025 in the Bar & Lounge where R1’s belongings still remained in the community. The family gradually removed R1’s belongs with a date of 10/05/2025 documented as the official move out date. R1’s belongings remained in the community from 06/30/2025 to 10/05/2025 a total of 97 days as documented by facility records. The community policy states that after the 90th day the community fee is non-refundable. The ED stated that the community strives to meet the needs of all residents and their families and acknowledges that this is a difficult time. As a courtesy to the family, the ED confirmed that they will honor the families proposed dates, which is not typical. The community fee refund will be re-calculated based on R1’s move-in date of June 30, 2025, through the expiration date of September 7, 2025, a total of 69 days. The community will issue a refund based on the initial fee of $6,000, minus a $500 assessment fee. The refund will reflect 40% of that amount, which is $2,200. Additionally, the community will honor the families proposed move out date of September 11th, 2025, as the end of rent date. The facility processed a one-time check dated 11/18/2025 in the amount of $10,359.24 reflecting the community fee adjustment to reflect 69 days, rent adjustment to reflect a move out date of 9/11/2025. Staff interviews revealed that R1 expired on 09/07/2025. R1’s belongings remained in the community after September 11th and were completely removed at the end of September or beginning of October, the exact date is unknown. R1 had a majority of their big furniture items moved around September 11th however small items remained in their apartment. Report continued on LIC 9099-C PAGE 3... (PAGE 3) Report continued from LIC 9099-C PAGE 2... R1 had a celebration of life at the community on 09/28/2025 and R1’s belongings were still in their apartment. R1’s family gradually removed R1’s belongings. Interviews with W1 revealed that AR hired their company to move R1’s belongings to a storage unit. The company moved R1’s belongings on 9/12/2025. The company typically moves large furniture items. The family was also taking things to their car at the same time. They are unsure if all belongings in the room were fully vacated on that day. Documents and Record review revealed that R1 moved into the community on 06/30/2025 and expired on 09/07/2025. R1 moved out of the community on 10/05/2025. R1 had their celebration of life at the community on 09/28/2025. Invoice dated 9/12/2025 indicated three (3) hours of service to move out R1's belongings. Documented conversation of 09/28/2025 indicated R1 still has items in their apartment. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff did not provide authorized representative a refund after resident passed away is deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Dec 5, 2025 · control 29-AS-20251106161820

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility at 10:04 a.m. to conduct an unannounced continuation of the annual inspection that began on October 23, 2025 (10/23/2025). Upon arrival LPA was greeted by front door receptionist and explained the reason for the visit. The LPA met with Executive Director (ED) Kailey Vanderwall and reason for the visit was explained. Entrance interview. During the annual inspection that was conducted on 10/23/2025 LPA Mosley conducted the full physical plant tour LPA observed the common areas, surrounding grounds / outdoors, nine (9) randomly selected resident bedrooms, of which six (6) in assisted living and three (3) in memory care, resident and community / public restrooms, kitchen, reviewed ten (10) personnel records, nine (9) resident records including home health and hospice records, and obtained pertinent documentation. During today’s visit, starting at 10:14 a.m. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns, and facility is in compliance with Title 22 Regulations. The following was noted: The facility is a double-story residence that consists of a memory care unit, and an assisted living unit. There are eighty -six (86) total apartments in the facility, fifty-nine (59) assisted living of which ten (10) are open studios, twenty-three (23) are one bedrooms, fifteen (15) are two (2) bedrooms, and eleven (11) studios with a double occupancy in the two (2) bedrooms, one (1) bedrooms, and open studios with a one hundred and seven (107) capacity. There are twenty-seven (27) apartments in memory care of which twenty one (21) are studios and six (6) one (1) bedrooms with a double occupancy in the open studios, and one (1) bedrooms with a capacity of thirty- three (33) with a total capacity of one hundred and forty (140) in all. They are approved for eight (8) bedridden residents, and have a hospice waiver for fifteen (15). Report Continued on LIC 809-C PAGE 2... (PAGE 2) Report Continued from LIC 809-C... Facility Records: LPA reviewed the quarterly inspections, testing and maintenance reports for the wet pipe and fire sprinkler system conducted on 01/15/2025, 05/05/2025, and 07/16/2025 indicating a pass in all areas. The annual fire alarm system inspection report conducted on 07/16/2025 where all three- hundred -thirty-seven (337) smoke alarms, carbon monoxide detectors/ devices including but not limited to auxiliary, control, indicating, initiating, supervisory devices were tested, functioned properly, serviced and passed. The last twenty-four (24) hours of the alert system and pendant activity used by residents to alert staff for assistance was reviewed. The facility’s alert system includes a call button installed in every restroom and a pendant-style device worn as a necklace by residents. Both systems are integrated and designed to generate alerts that immediately notify staff when assistance is needed. The review revealed that, based on forty-four (44) recorded alerts, staff responded within one (1) to thirty- seven (37) minutes. LPA reviewed facility notes related to times that were longer than fifteen (15) minutes. The daily vehicle inspections, and annual Inspection report that was conducted on 03/05/2025 was reviewed for all facility vehicles. All records were in order. Infection Control / Emergency disaster planning: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required. The last emergency disaster drill took place on 09/4/2025 and conducted monthly covering all shifts and areas of emergency disasters. LPA reviewed the fire drill report conducted on 08/15/2025 at 10:45 p.m. in the memory care unit of a simulated fire in a resident room and a disaster drill on 08/15/2025 at 11 p.m. of a simulated extreme weather flooding both indicating a pass. The last in service training on infection control was conducted on 09/24/2025. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard. Interviews: Starting at 1:26 p.m nine (9) staff interviews were conducted which indicated that staff are knowledgeable in resident rights, the various forms of abuse, and appropriate reporting procedures. Starting at 3:00 p.m. LPA conducted three (3) group interviews of eleven (11) residents total during the facilities OctoberFest festival. Group one (1) consisted of five (5) residents, group two (2) and three (3) consisted of three (3) residents each. Resident interviews revealed that no concerns were noted or expressed at the time of the visit. Residents reported that a variety of activities are offered and provided, and food substitutions are available upon request. Report Continued on LIC 809-C PAGE 3... (PAGE 3) Report Continued from LIC 809-C PAGE 2... Medication Audit: There are two (2) medication rooms located on each side of the facility. Med Techs distribute medication at the appropriate times to residents in care. Medication audit for nine (9) residents was conducted. Six (6) in the Assisted Living Unit and three (3) in the Memory Care Unit of which one (1) on Hospice. The following was observed. The medications were stored in the medication rooms in carts, both were locked and inaccessible to the residents. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. LPA advised ED that a few of the start dates were difficult to read and suggested reviewing / clearing up the writing to make it easily legible. No errors observed during review. Documents: Documents obtained during the visit include: Limited Liability insurance. LPA obtained the following documents on the initial annual visit on 10/23/2025 : Facility / Staff roster and a Resident roster. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report reviewed and provided.the state’s words, verbatim · CDSS document, Oct 24, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 10:00 a.m. Upon arrival LPA was greeted by front door receptionist and explained the reason for the visit. The LPA met with Executive Director (ED) Kailey Vanderwall and reason for the visit was explained. Entrance interview. The LPA and ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: The facility is a double-story residence that consists of a memory care unit, and an assisted living unit. LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced on 02/27/2025. LPA observed all the required postings in the Activity Room near the entrance area, and throughout the facility. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Activities observed on both units. In the Memory Care until morning exercise, and daily chronicles were observed. Common Areas: These included the beauty salon, library, activity room, theater, fitness center, bistro, and dining areas in assisted living and memory care units. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Fireplaces were properly screened. LPA observed designated storage / utility rooms with emergency food and water. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents in both, the memory care unit courtyard and the assisted living courtyard. Parking is available for residents and visitors. Report Continued on LIC 809-C PAGE 2... (PAGE 2) Report Continued from LIC 809-C... Bedrooms: There are eighty -six (86) total apartments in the facility, fifty-nine (59) assisted living and twenty-seven (27) in memory care. LPA observed nine (9) randomly selected resident bedrooms, of which six (6) in assisted living and three (3) in memory care. All resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. All passageways were observed to be clear of obstructions. Restrooms: Resident restrooms appeared clean, sanitary and in operating condition with grab bars and to be equipped with a slip resistant surface / mat. The restrooms were sufficiently stocked with supplies and paper towels. Towels and washcloths are not shared among the rooms. The hot water temperature was measured and ranged between 106.0 - 120.0 degrees Fahrenheit all within the required range. LPA advised ED of the regulatory standard of 105-120 degrees Fahrenheit as the water was at the maximum. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are available for residents in the dining area. Knives are stored and inaccessible to residents. Refrigerator and food pantry were checked for proper labels and expiration dates. Records: Personnel Records were reviewed beginning at 11:53 a.m. Ten (10) Personnel files including the ED's file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. Resident Records were reviewed beginning at 1:05 p.m. Nine (9) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order. DOCUMENTS: Documents obtained during the visit include: Facility / Staff roster and a Resident roster. Due to time constraints the LPA will return to complete the annual at a later date. Exit interview conducted. Copy of report reviewed and provided.the state’s words, verbatim · CDSS document, Oct 23, 2025

Allegation investigated: Staff do not ensure resident is provided adequate food service. Staff does not ensure resident's food diet is being followed.

Licensing Program Analyst (LPA), Esther Cortez conducted a subsequent complaint visit for the above allegations. Upon arrival, LPA met with Executive Director Kailey Vanderwall and was explained the reason for the visit On 04/01/25, the LPA conducted a physical plant tour to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations, conducted three (3) staff, four (4) residents interviews, a file review and and obtained copies of resident records and other pertinent documents relevant to the investigation. On 07/16/25, the LPA conducted a file review, conducted interviews with the ED, two (2) staff, and two (2) residents, and toured the Kitchen. On 07/17/25, the LPA conducted a file review, conducted interviews with the ED, and three (3) staff. On 07/21/25, the LPA conducted a file review,collected pertinent documents relevant to the investigation, conducted interviews with the ED, Health Service Director, one (1) staff and four (4) residents. During today's visit the LPA conducted a file review. Report will continue on LIC9099-C, 2nd page. Unsubstantiated Regarding the allegations, “Staff do not ensure resident is provided adequate food service and Staff does not ensure resident's food diet is being followed” it is the concern of the Reporting Party (RP) that Resident 1 (R1) was placed on a diet by their Primary Physician and staff does not follow it. Additionally, when R1 requests a specific breakfast, R1’s meal will be cold when delivered. File review revealed that R1 has a doctor’s order for a strict anti-reflux diet, mechanical soft diet, no acid, no seasoning, no sauce, and no beef, does not drink thin liquids, drinks ensure and cream of wheat, signed and dated 01/31/25. Nine (9) out of ten (10) residents interviewed revealed that they have no concern regarding the food provided, they are provided with adequate food service, staff know what the residents can and cannot eat, and that the community provides balanced meals, follows their diet and provides alternate dishes if needed. An interview with R1, revealed that they only eat breakfast at the community and buy their own canned food to eat during lunch and dinner, however the community prepares it for them or they grind it. R1 states that the staff prepares their food and grinds it but it is not the right consistency. On 04/01/2025, the LPA observed R1 eating a plate of canned corn, green beans, peas, carrots, and roasted turkey that seemed to be in a smooshy consistency and covered with ensure, and on the side bread inside milk. An interview with the communities Chef, revealed that everyone in the kitchen knows R1 and are very aware of R1’s diet (mechanical soft) as R1 has a history of complaints regarding their food no matter what they do. Furthermore, staff interviews revealed that the community provides breakfast, lunch and dinner, as well as snacks, however R1 is very particular about their food and only eat breakfast provided by the facility and buy their own food but for lunch and dinner, the staff always follow all the residents’ diets and even accommodated to the residents’ preferences. Additionally, R1 repeatedly complains about the consistency and temperature of their food and staff will take it back to the kitchen and have them re do it. Although the allegation may have happened or is valid, there is not enough evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated at this time. Exit interview was conducted and report provided. Regarding the allegation, “Staff does not answer resident's call button”; it is the concern of the Reporting Party (RP) that Resident 1 (R1) has been needing help getting in and out of bed, has pushed their call button on multiple occasions but staff never goes, and they will have to try to move in and out of bed on their own. No date(s) provided. LPA reviewed pendant records for R1 from 03/19/25, starting at 6:16 PM to 04/1/25 ending at 10:42 PM. R1’s pendant records revealed that ten (10) out of one hundred and twenty-five (125) pendant calls R1 made were never responded to. Oakmont’s PHB history indicated that on all 10 pendant calls made that were not responded to, the calls were announced 9 times. The LPA did not observe any charting notes from staff that indicated R1 had been helped but denied staff to reset their pendant during that date period. Based on the record review, there is sufficient evidence to support the allegation and that a violation occurred; therefore, this allegation is deemed SUBSTANTIATED. The following deficiency was cited from the CA Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview held, appeal rights and report copy provided.the state’s words, verbatim · CDSS document, Aug 26, 2025 · control 29-AS-20250324085112

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 29, 2025

87468.2(a)(4)residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidence by: Based on records review, the licensee did not comply with the section cited above as Staff did not respond to R1’s call for assistance in a timely manner, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2025

Plan of correction: ED agreed to have an in service with all staff regarding how to respond resident calls in a timely manner and charting if resident refuses staff to clear the call. Will submit proof of inservice to CCL by 08/29/25

Allegation investigated: Facility staff failed to provide hospital with POA contact information

Licensing Program Analyst (LPA), Esther Cortez conducted a subsequent complaint visit for the above allegation. Upon arrival, LPA met with Executive Director Kailey Vanderwall and explained the reason for the visit. On 07/28/25, the LPA conducted interviews with the ED, one (1) staff, and Resident 1's (R1's) POA telephonically, conducted a file review and collected pertinent documnets relevant to the investigation. It was determined further investigation is required prior to issuing findings. During today's visit the LPA conducted a file review. Report will continue on LIC9099-C, 2nd page. Substantiated Regarding the allegation, "Facility staff failed to contact POA regarding medical emergency" it is the concern of the reporting party (RP) that On 7/17/2025, Resident 1 (R1) was sent to St. John's Regional Medical Center due to a rash on their face (suspected shingles), however when the facility staff sent R1 to the hospital they did not notify the POA. To investigate the allegation the LPA conducted interviews and a file review. Interview with R1's Power of Attorney (POA) revealed that they were notified of R1's hospital visit however it was after R1 was already admitted to the hospital, and that the hospital would not release any information to them due to the hospital not being provided their information. R1's POA stated they did receive three calls from facility staff about the incident and it could have been the same day R1 was taken to the hospital but after they were already admitted. Interview with Staff 1 (S1) revealed that they attempted to contact R1's POA however the Resident Information form used at the time of R1's hospital visit had the wrong POA listed. They were able to get R1's POA contact information and do not recall the exact date but recall speaking to them. In addition they stated that residents are still to be attended in emergency situations regardless if they were able to successfully contact the POA. A review of R1's Inpatient Discharge Instructions from St. John's Regional Medical Center revealed that R1 was taken to the hospital on 07/21/25 which was the date confirmed by R1's POA that they were notified of the incident. Based on interviews and records reviewed this allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted and report provided to the Executive Director. Report was amended. Amended report emailed for signature. Signature on file. Regarding the allegation, "Facility staff failed to provide hospital with POA contact information"; it is the concern of the Reporting Party (RP) that On 7/17/2025, Resident 1 (R1) was sent to St. John's Regional Medical Center due to a rash on their face (suspected shingles), however staff did not provide R1’s POA contact information to the hospital. To investigate the allegation the LPA conducted interviews and a file review. Interview with R1's Power of Attorney (POA) revealed that they were notified of R1's hospital visit after R1 was already admitted to the hospital, and that the hospital would not release any information to them due to the hospital not being provided their information. Additionally, the POA revealed that if they had been notified sooner of the hospital visit they would have asked for R1 to be taken to a different hospital. Interview with Staff 1 (S1) revealed that the Resident Information form used at the time of R1's hospital visit had the wrong POA listed. When the LPA showed S1 the form that was provided to the LPA as part of the emergency packet, S1 revealed that was not the same form used the day of the hospital visit. S1 indicated that they called the "POA" that was listed on the previous Resident Information form and when they answered they notified them that they would like to be taken off as R1's "true POA" and provided S1 with R1's actual POA. S1 attempted to call R1's actual POA with the information provided to the them but did not leave a voicemail with sensitive information due to not knowing if that was actually R1's POA. S1 further revealed that they recall giving the actual POA's phone number to the paramedics on a sticky note. Lastly, it was revealed that the Regional Memory Care Director updated their system with the correct POA information after the incident and a new face sheet was printed. On 07/28/25, LPA Cortez was notified by Witness 1 (W1) that in 2023, R1's POA shared their contact information and POA paperwork with the staff and W1 shared it with them as well. File review revealed that R1 has a Power of Attorney for Health Care on file with the correct POA listed on file. The LPA also observed a Resident Information form on file with a primary and second emergency contact, which were not the POA. Based on staff interview and file review, there is sufficient evidence to support the allegation and that a violation occurred; therefore, the above allegation is deemed Substantiated at this time. The following deficiency was cited from the CA Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview held, appeal rights and report copy provided.the state’s words, verbatim · CDSS document, Aug 20, 2025 · control 29-AS-20250728105832

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Aug 21, 2025

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available ...This requirement is not met as evidenced by: Based on interviews and file review the licensee did not comply with the section cited above as R1's emergency packet was not updated with the resident correct POA information which posed a potential health and safety or personal risk to persons in care.the state’s words, verbatim · CDSS document, Aug 20, 2025

Plan of correction: Information has been updated. Licensee agrees to submit a letter of understanding of regulation 87506 in its entirety by 08/21/25.

Allegation investigated: Staff does not ensure resident's medical needs are being met. Staff does not ensure resident's medications are refilled in a timely manner.

Licensing Program Analyst (LPA), Esther Cortez conducted a subsequent complaint visit for the above allegations. Upon arrival, LPA met with staff and explained the reason for the visit. Executive Director Kailey Vanderwall arrived shortly thereafter and was explained the reason for the visit. On 04/01/25, the LPA conducted a physical plant tour to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations, conducted three (3) staff, four (4) residents interviews, a file review and and obtained copies of resident records and other pertinent documents relevant to the investigation. On 07/16/25, the LPA conducted a file review, conducted interviews with the ED, two (2) staff, and two (2) residents, and toured the Kitchen. On 07/17/25, the LPA conducted a file review, conducted interviews with the ED, and three (3) staff.During today's visit the LPA conducted a file review,collected pertinent documents relevant to the investigation, conducted interviews with the ED, Health Service Director, one (1) staff and four (4) residents. Report will continue on LIC9099-C, 2nd page. Unsubstantiated Regarding the allegation, “Staff does not ensure resident's medical needs are being met”; it is the concern of the Reporting Party (RP) that Resident 1 (R1) has been diagnosed with lymphedema and has peripheral neuropath prior to admission to the facility and was scheduled for two appointments with the Physician from the facility but the Physician cancelled both appointments. It was further alleged that R1 does not need to go to the hospital but needs more hands-on care from facility staff, R1 sustained a fall and their lymphedema was triggered and R1 has asked for more help but staff does not help. The LPA reviewed records which indicated R1 was receiving medical care with physicians. R1 received home health services at the facility. R1 received assistance from care staff as well. Interviews with staff and charting notes confirmed R1 was receiving care, however oftentimes R1 would refuse care or refuse to go to scheduled appointments. Interviews with other residents confirmed they receive the care they need from staff and stated all of their care and medical needs were met. Based on interviews and records reviewed this allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation, “Staff does not ensure resident's medications are refilled in a timely manner”; it is the concern of the Reporting Party (RP) that on 03/23/25, Resident 1 (R1) needed their topical medication for their hands and toes but the Med Tech didn’t have any to give to them because the staff did not refill R1’s medication on time. Staff interviews revealed that they submitted refills on time, denied R1 was ever without medication due to the community not refilling them on time. However, R1 has orders for topical medications that can be self administered and remain at bedside with R1 and R1 will not notify MedTechs that their medications will be running out soon and often notify MedTechs they need a refill once the medications are already done. Additionally, file review revealed that R1 has a history of being non-compliant with medications and has a history of refusal of medication. There was no indication that mediations were not refilled on time by staff during file review. Lastly, all interviews with residents revealed that they have no concerns regarding medications not being refilled on time. Based on interviews and records reviewed this allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Report provided.the state’s words, verbatim · CDSS document, Jul 21, 2025 · control 29-AS-20250324085112

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff does not ensure resident's bathroom is clean.

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint investigation visit regarding the above noted allegation. LPA met with staff and explained the reason for the visit. Executive Director Keiley Vanderwall arrived shortly thereafter and was explained the reason for the visit. On 07/25/24, LPA Camara conducted interviews with the ED, memory care director, and health services director starting at 10:32 a.m. LPA obtained pertinent documents starting at 10:48 a.m. LPA conducted a telephone interview with a witness at 11:16 a.m. On 05/21/25, LPA Cortez interviwed the ED, Resident 1 (R1), toured R1's room, and obtained pertinent documents. On 05/22/25, LPA Cortez interviewed one (1) witness, two (2) staff, toured R1's room and briefly spoke with R1, conducted a file review and obtained pertinent documents. On 07/16/2025, between 8:45 a.m. and 4:00 p.m. LPA Cortez conducted interviews with the ED, and four (4) staff, conducted file review, and toured R1's restroom in the Memmory Care unit. During today's visit the LPA interviewed the ED, conducted a file review and obtained pertinent documents relevant to the investigation. Report will continue on LIC9099-C, 2nd page. Substantiated Regarding the allegation, “Staff isolates resident in room” it is the concern of the Reporting Party (RP) that on or about 05/31/24, Resident 1 (R1) was diagnosed with scabies and the facility isolated the resident for four weeks. File review revealed that on 05/30/24, staff made R1’s Primary Care Physician (PCP) aware of scabs/sores on R1’s back via email by sending them photos of R1’s back and asked to “please advise”. Once R1’s PCP advised that scabies treatment would be ordered, staff asked if they should take scabies precautions and isolate R1 to which R1’s PCP replied with “Until treatment ideally.” Staff then notified the PCP, that their corporate office was having R1 isolate and release with MD clearance after treatment. PCP responded that they would order HH so they could give clearances after treatment. LPA Cortez observed a doctor’s order for R1 to come off isolation by their PCP, dated 06/26/24. Additionally, interviews conducted with Executive Director Kailey Vandewall, Memory Care Director Denise Wadkins, and Health Services Director (HSD) Ian Gadea on 07/25/24, by LPA Camera, revealed that R1 was placed in isolation due to possible scabies, the doctor told them to isolate the residents to prevent spread to others. In addition, they followed Oakmont protocol for scabies which states to follow doctors orders. Interviews conducted with ED Kailey by LPA Cortez revealed that even though R1 was placed in isolation, they were still continuing the same care it just looked a bit different, staff made sure to be using the proper PPE, and R1 had a 1:1 with them during this period. Although the allegations may have happened or is valid, there is not sufficient evidence to prove that a violation occurred, therefore the allegation is deemed Unsubstantiated at this time. Regarding the allegations. “Staff does not ensure resident is provided toiletry supplies, and Staff does not ensure resident's hygiene needs are being met,”; it is the concern of the Reporting Party (RP) that in 2024, R1 was not being provided toilet paper due to clogging the toilet, and that R1 was unkempt and needed increase care with toileting and showering. To investigate the allegation the LPA visited R1 and conducted interviews. On 05/21/25, 05/22/25, and 07/16/25 the LPA observed R1’s restroom with toilet paper accessible to the resident. On 05/21/25, and 05/22/25 the LPA observed R1 to have a neat and well-maintained appearance. Additionally, on 05/21/25, an interview conducted with R1 revealed that they have no concerns, staff help them and treat them well. Report will continue on LIC9099-C 3rd page. Most of the staff interviews revealed that they have never seen R1 unkempt, and they have never seen R1’s bathroom without toilet paper unless they run out and there is additional supply of toilet paper in a locked closet inside the resident’s room. The information obtained during the investigation did not include sufficient evidence to corroborate the allegations. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegations are deemed Unsubstantiated at this time On the allegation, “Staff does not safeguard resident's personal belongings” it is the concern of the Reporting Party (RP) that Resident 1 (R1) had a lot of expensive clothing brand and on or about 5/30/24, R1 was diagnosed with scabies, and isolated. During this time most of R1’s clothing and bedding was placed in plastic trash bags to be laundered separately in hot water, and the facility lost most of R1’s clothing and bedding or shrunk their clothing. Most of the staff interviewed revealed that they had no knowledge of any missing items for R1, and all clothing and bedding that was laundered were returned. All care staff interviewed denied ever losing or taking any of R1’s belongings. Interviews conducted with ED Kailey revealed that all items were placed back, however there were some clothing that did shrink due to being laundered in hot water, which was part of the Oakmont protocol for Scabies. Additionally, the ED stated that they have offered R1’s POA the opportunity to give the ED a list of items (and their value) that they believe were missing or shrunk and the ED would work with them in processing a refund. File review revealed that R1’s signed Admission Agreement and the facility’s Theft and Loss Policies and Procedures indicate that the facility will maintain an inventory of personal property upon request, unless the resident or responsible party does not wish to complete the inventory. Additionally, the Theft and Loss Policies and procedures indicate that the facility reports lost items of $100 or more to law enforcement and investigate missing items. File review revealed that R1’s responsible party indicated they do not wish to inventory any personal property. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegations are deemed Unsubstantiated at this time. Exit interview conducted. Report provided. Regarding the allegation, “Staff does not ensure resident's bathroom is clean”; it is the concern of the Reporting Party (RP) that feces on R1’s bathroom floor was observed. One staff member confirmed that on more than one occasion they saw feces on the floor of R1’s bathroom that looked dry as if it had been there for an extended period and has questioned colleges as to why they did not clean it during previous shifts. On 07/16/2025, the LPA toured R1’s locked bedroom including their bathroom with Executive Director Kailey and at 3:51 p.m. observed dry feces in R1’s bathroom floor, toilet bowl seat with brown skid marks, and the yellow urine stains in the front of the toilet base. Based on the information gathered, the Department has sufficient evidence to support the allegation, therefore the allegation Staff does not ensure resident's bathroom is clean is Substantiated at this time. The following deficiency was cited from the CA Code of Regulations, Title 22 (See LIC9099-D.). Failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights and report copy provided.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 29-AS-20240723161809

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Jul 24, 2025

87303(a)(1) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:Based on observations and interview, the licensee did not comply with the section cited above as the LPA observed dry feces in R1's bathroom floor which posed a potential health and safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: ED agrees to have all care staff and house keeping staff training on how to maintain bathrroms in a clean and sanitary condition. Submit to CCL by 7/24/25.

Allegation investigated: Resident lost significant amount of weight.

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint investigation visit regarding the above noted allegations. LPA met with Business Office Director Ricardo Viveros and explained the reason for the visit. Executive Director Keiley Vanderwall was not able to be present during today's visit. On 07/25/24, LPA Camara conducted interviews with the ED, memory care director, and health services director starting at 10:32 a.m. LPA obtained pertinent documents starting at 10:48 a.m. LPA conducted a telephone interview with a witness at 11:16 a.m. On 05/21/24, LPA Cortez interviwed the ED, Resident 1 (R1), toured R1's room, and obtained pertinent documents. During today's visit the LPA interviewed one (1) witness, two (2) staff, toured R1's room and briefly spoke with R1, conducted a file review and obtained pertinent documents. Report will continue on LIC9099-C, 2nd page. Substantiated Regarding the allegation, “Resident lost significant amount of weight”. It is the concern of the Reporting Party (RP) that on or about 05/31/24, Resident 1 (R1) was diagnosed with scabies and the facility isolated the resident for four weeks. During the isolation period the resident lost a lot of weight, from about 112 lbs. R1 dropped to 103 lbs. and went from a size 6 to a size 2. File review revealed that Resident #1 (R1) was admitted to the facility on 1/13/24. Per R1’s Monthly Vital Signs and Weight Record, on 1/25/24, R1 weighed in at 121 lbs. and on 07/25/24 (shortly after the complaint was submitted), R1 weighed in at 108 lbs. This is a 13 lbs. weight loss within a 6-month period. Furthermore, R1 weighed in at 114 lbs. on 5/31/24, having a 6 lbs. weight loss within 2 months. The community’s Charting Notes starting on 5/17/2024 and ending on 08/05/2024 indicated that during that time frame R1 was being treated for Scabies, placed on isolation on 05/30/24 until MD gives clearance to leave, on 06/26/24 an order was received from residents PCP that R1 was able to come off isolation, and on 07/06/24 PCP was notified that R1 will be in isolation. However, R1’s charting notes did not reflect any doctor appointments to address the issues with weight loss, additionally no mention of weight loss was charted on these notes. Interview conducted by LPA Camara with the ED on 07/25/24, revealed that the ED was not aware R1 had lost so much weight and suspected it could have been muscle loss due to the isolation period because R1 is normally quite active, and the ED planned on asking R1’s doctor if they should put R1 on Ensure to get some weight back on them. Interview conducted by LPA Camera with R1’s Primary Care Physician (PCP) revealed that they do not weigh the resident because they are mobile, but that they had not realized R1 had lost that weight and was not aware of a medical cause for the weight loss. File review did not indicate any notification of weight loss to R1’s PCP by the community. During today's visit, Business Office Director was not able to provide any records of staff addressing R1's weight loss in 2024 with their PCP. Based on file review and interviews, the Department has sufficient evidence to support the allegation, therefore the allegation Resident lost significant amount of weight is Substantiated at this time. The following deficiency was cited from the CA Code of Regulations, Title 22 (See LIC9099-D.). Failure to correct the deficiencies may result in civil penalties. Exit interview held, appeal rights and report copy provided Regarding the allegations, “Resident contracted scabies while in care and Resident developed sores while in care”; It is the concern of the Reporting Party (RP) that on or about 05/31/24, Resident 1 (R1) was diagnosed with scabies and R1 had scabs/sores on their back from scratching. File review revealed that on 05/30/24, R1’s Primary Care Physician (PCP) was notified that R1 was noted scratching chest, upper/lower back, small dry red/brown spots were noted, pictures were sent over, and PCP was asked to please advise. Interviews with the ED, staff, R1’s PCP and charting notes revealed that R1 was diagnosed with Scabies/suspected Scabies on 05/30/24 by their Primary Care Physician and was prescribed treatment. File review revealed that staff addressed R1’s rash and were following R1’s orders. The ED revealed that R1’s Power of Attorney (POA) made different Dermatology appointments and R1’s reoccurring rash ended not being scabies. Interview conducted with R1’’s POA revealed that the error came from R1’s PCP who misdiagnosed R1 with Scabies, they took R1 to several Dermatologist and R1 had a bacterial infection and recovered after they were given antibiotics. A review of an Urgent Care Center doctors order dated 08/01/24, indicated that R1 did not have a rash due to scabies. Information obtained from file reviewed and interviews conducted revealed R1 was diagnosed with Scabies/possible scabies and presented a rash on their back, however R1 was being seen and treated by their PCP. Staff interviews also revealed that staff was following facilities Scabies protocol, and all doctor’s orders. Therefore, the allegations are deemed Unsubstantiated at this time. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, May 22, 2025 · control 29-AS-20240723161809

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jun 5, 2025

87466 Observation of the resident. ... When changes such as unusual weight gains or losses.. are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on the information gathered via interviews and record review, although the facility’s staff documented R1's weight loss they did not address it with their PCP which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Business Office Director agreed to provide an in service to staff related to observation of the resident and addressing changes observed to PCP and resident's responsible party. Proof of training will be sent to CCL by POC due date of 06/05/25.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. The LPA met with Executive Director Kailey Vanderwall and explained the reason for the visit. Entrance interview conducted. The reason for today's inspection is to follow up on a self-reported death report received on 03/11/2025. The report pertains to the death of Resident #1 (R1). It was reported R1 was sent to the hospital on February 23th due to a fall and passed away on March 8th at the hospital. During today's visit, the LPA conducted an interview with the Executive Director, Health Service Director, one (1) resident, conducted a brief tour of the facility and obtained copies of pertinent documents. Further investigation is required prior to issuing findings. Exit interview conducted. A copy of the report was issued to the Executive Director.the state’s words, verbatim · CDSS document, Mar 20, 2025

Allegation investigated: Staff do not prevent resident from entering other residents' rooms

Report was amended to reflect allegation was Substantiated. Amended Report emailed for signature. Signature on file. Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subseqent complaint visit for the above allegation. Upon arrival, LPA met with the Executive Director (ED), Kailey Vanderwall , and was explained the reason for the visit. Entrance interview conducted. On 02/12/2024, between 01:50 p.m. and 5:00 p.m., the LPA interviewed the ED, six (6) residents, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 01/14/2024, between 12:35 p.m. and 4:15 p.m., the LPA interviewed the ED, three (3) residents, five (5) staff, and obtained copies of resident records and other pertinent documents relevant to the investigation. During today's visit the LPA interviewed the current ED, Kailey Vanderwall and conducted a file review. Report will continue on LIC9099-C, 2nd page. Substantiated On the allegation " Staff do not prevent resident from entering other residents' rooms"; it is the concern of the reporting party (RP) that Resident 1 (R1) goes into other resident’s rooms and roams the halls at night. It was further reported that R1 needs more care than what staff can provide. To investigate the allegations the LPA conducted a file review and interviews. A review of R1’s charting notes from 10/01/2023 to 02/14/2024 revealed that R1 had been wondering into resident’s rooms and wondering the halls during the day and at night very confused on different occasions. Additionally, on 10/04/2023, it was charted that R1 tried to take shirts from another resident and when the resident told them no, R1 bit them. On 12/24/2023, it was charted that at approximately at 8:37 p.m. it was reported that R1 could not be found, and R1 was found at 10:55 p.m. Majority of the residents interviewed revealed that R1 has entered their room uninvited, with one of the residents stating that they have voiced concerns to management and another resident stating that they feared R1. Staff interviews revealed that based on R1’s behaviors and needs they believed R1 required a higher level of care, such as being place in the Memory Care unit. Interview conducted with current ED, Kailey Vanderwall during today's visit revealed that R1 has been placed in memory care as of 04/24/2024. Based on interview and record review, the allegation that " Staff do not prevent resident from entering other residents' rooms " is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D). Exit interview conducted. A copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 16, 2025 · control 29-AS-20240206103814

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jan 24, 2025

Observation of the Resident:The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above as staff and file review revealed R1 was observed to be declining, and wondering into other residents rooms which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 16, 2025

Plan of correction: Current Executive Director reported that the facility residents are observed and monitored regularly and any significant change is reported accordingly. Will Submit a written self certification of understanding the regulation cited and their plan to ensure future compliance. Will submit Statement by 1/24/25.

Allegation investigated: Resident was left in an unkempt room overnight. Resident had access to an item that could pose a danger.

Licensing Program Analyst (LPA), Erica Mosley conducted an unannounced subsequent complaint visit to deliver findings the above allegations. Upon arrival, LPA met with Executive Director Kailey Vanderwall and explained the reason for the visit. On todays visit LPA Mosley conducted a physical plant tour at 10:35 a.m. to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. On 12/17/2024, LPA Esther Cortez between 03:15 p.m. and 5:00 p.m., interviewed the ED, MC Director, two (2) staff, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 12/19/2024, between 08:30 a.m. and 3:00 p.m., LPA Cortez conducted a file review and interviewed six (6) staff. Report continued on LIC9099-C.... Substantiated Report continued from LIC9099.... On the allegations, “Resident was left in an unkempt room overnight and Resident had access to an item that could pose a danger,”; it is the concern of the reporting party (RP) that on 10/15/2024, Resident 1 (R1) in Memory Care was able to get a hold of a fire extinguisher, pulled the pin, and made a mess all over their room with the fire extinguisher powder. RP further reported that they did not know if the powder was toxic, and R1 was left in their room with all the powder overnight until it was cleaned on 10/16/2024. Lastly, the RP reported that R1 grabbed the fire extinguisher again and staff keep leaving it accessible. Interviews conducted with staff revealed that six (6) out of nine (9) staff had knowledge of R1’s incident with the fire extinguisher. Staff 1 (S1) revealed that they do not remember the exact date but does recall that a few months ago while working their NOC shift, during their second rounds of checking on the residents between 1:00 a.m. and 3:00 a.m. they found that R1 had taken a fire extinguisher to their room and sprayed the whole room. They did not know if was dangerous to inhale and the MedTech present called the Memory Care Director (MCD) and advised them of the incident. The MCD called them back and informed them that they had spoken to the Director of Maintenance and was told that it was okay to leave R1 in the room. S1 revealed that R1 was then left in their room. When asked regarding who and when was the room cleaned, they responded that they put a work order for the next day and the room was cleaned until the next day by the maintenance staff or the housekeeper. Staff 2 (S2) revealed that they were informed of the incident the morning of the incident, went to clean the room, observed the resident in the room, the powder was all over the room, and they cleaned it with a vacuum. Staff 3 (S3) revealed that after S2 cleaned the room they went and cleaned the stains on the carpet. Furthermore, staff revealed that grabbing the fire extinguisher was a known behavior of R1, staff re-direct R1 anytime he grabs a fire extinguisher, and the fire extinguishers are accessible to the residents. On 12/17/2024, the LPA observed the fire extinguishers stored in unlocked, white fire extinguisher cabinets with a glass cover, accessible to the residents in care. Report continued on LIC9099-C.... Report continued from LIC9099-C.... The LPA obtained twelve (12) photos, that were reported to be of R1’s room and bathroom with the fire extinguisher powder. Photos #1 and #2 (P1, P2) show a fire extinguisher on a carpeted floor in a dark room. The carpet appears to have a large amount of visible yellow powder near the extinguisher. The texture of the carpet is clearly visible, you can see footprints on top of the powder. The corner of a bed is seen in the lower right corner of the image in P1, and the bottom of a person’s foot is seen on top of the bed. P3 shows a lighted bedroom with a bed, two side tables, and a lamp. The bed has pillows and a blanket, and there is a dark blanket draped over the foot of the bed. A recliner chair is visible in the background. The carpeted floor in the foreground appears to have a large amount of powder on the carpet, the powder is scattered and spread unevenly over the carpet. Footprints or patterns are visible. Near the left side foot of the bed appears to have a heavier concentration of the fire extinguisher powder compared to the rest of the carpet. P4-P9 show the powder throughout the room on the hallway carpet, bathroom floor, over the furniture and blankets on the bed. All photos have the date stamp of 10/16/2024. Regarding the allegations, “Resident was left in an unkempt room overnight and Resident had access to an item that could pose a danger,” information obtained throughout the investigation revealed that on 10/16/2024, R1 had access to a fire extinguisher despite the fire extinguisher cabinets having locking mechanisms and staff knowing that grabbing the fire extinguisher was a known behavior of R1. R1 pulled the pin and set it off in their room. Additionally, staff admitted to leaving R1 in the room overnight without the fire extinguisher powder being cleaned up until the morning staff arrived. Furthermore, photos revealed that R1’s whole room was covered with fire extinguisher powder. Based on the above information gathered, there is sufficient evidence to support the allegation and that a violation occurred; therefore, the above allegations are deemed Substantiated at this time. The following deficiencies were cited from the CA Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview held, appeal rights and report copy provided.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 29-AS-20241217142256

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a)(1) · Plan of correction due date: Dec 24, 2024

87303(a)(1) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Based on photos and interviews, the licensee did not comply with the section cited above as R1 was left in their room overnight with fire-extinguisher powder all over the room which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: ED agrees to submit plan on how they will ensure resident rooms are maintained in a clean and sanitary condition including during NOC shifts. Submit to CCL by 12/24/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(f)(1) · Plan of correction due date: Dec 27, 2024

87705(f)(1) Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on interviews and observation, the licensee did not comply with the section cited above, as R1 had access to fire extinguisher, despite staff knowing that grabbing the fire extinguisher was a known behavior of R1, which posed a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: ED agrees to submit a plan on how they will ensure items that could constitute a danger to the resident(s) will be stored inaccessible to residents with dementia.

Allegation investigated: Facility staff spoke inappropriately to resident. Facility staff refused to assist resident with mobility. Facility staff refused to assist resident with dressing.

Report has been amended. Amended report emailed for signature. Signature is on file. At 10:30 a.m., Licensing Program Analyst (LPA) Erica Mosley conducted a subsequent complaint investigation visit to deliver findings for the above allegations. The LPA met with Executive Director (ED) Kailey Vanderwall and explained the reason for the visit. On todays visit LPA Mosley conducted a physical plant tour at 10:35 a.m. to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. On 11/29/2023, the LPA received pertinent documents and conducted interviews with three (3) residents and two (2) staff from 03:18 pm to 4:15 pm. On 12/17/2024, the LPA interviewed the ED, MC Director, conducted six (6) staff interviews, four (4) resident interviews and obtained resident records and copies of pertinent documents relevant to the investigation. On 12/19/2024, between 08:30 a.m. and 3:30 p.m., the LPA conducted a file review, and three (3) staff interviews. Report continued on LIC9099-C.... Unsubstantiated Report continued from LIC9099.... On the allegations, “Facility staff spoke inappropriately to resident, Facility staff refused to assist resident with mobility, Facility staff refused to assist resident with dressing”; it was alleged that two (2) staff (S1, S2) called Resident 1 (R1) “fat”, “heavy”, and “disgusting,” refused to help R1 with mobility issues such as getting out of bed and refused to help change their clothes. Date was not provided. Interview conducted with R1 on 11/29/2023 revealed that they were confronted by a couple of workers in a mean way, staff told R1 to get ready and get dressed, however R1 is not able to do it by themselves. R1 further revealed that they have a problem with their memory and could not remember their names. Interviews conducted with staff revealed that S1 is no longer at the community and there is no staff with the name provided for S2 currently working at the community or during the time the complaint was submitted in November of 2023. All care staff denied speaking to any resident inappropriately and denied they have refused to assist residents. Three (3) out of thirteen (13) staff interviewed revealed that R1 voiced concerns to them about the above allegations, and have observed similar behavior from staff, however, all thirteen (13) staff revealed that they did not witness the noted allegations. Six (6) residents interviewed revealed that they have never been denied assistance or talked to inappropriately by any staff. On the allegations, “Facility staff spoke inappropriately to resident, Facility staff refused to assist resident with mobility, Facility staff refused to assist resident with dressing”; information gathered from interviews revealed that all care staff denied allegations, there is no staff by the name provided for S2, R1 could not remember the names of the staff when interviewed by the LPA, there were no witnesses, and six (6) other residents interviewed revealed they had no concerns. Based on interviews, although the allegation may be valid, at this time, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegations above are deemed UNSUBSTANTIATED at this time. Exit interview conducted. Today's report was reviewed and emailed to the Executive Director.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 29-AS-20231121093226

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Erica Mosley conducted a case management - deficiencies visit due to deficiencies discovered over the course of the investigation of complaint control number 29-AS-20231121093226. LPA met with Executive Director Kailey Vanderwall and explained the reason for the visit. On todays visit LPA Mosley conducted a physical plant tour at 10:35 a.m. to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. During the investigation, interviews conducted with staff revealed that six (6) out of ten (10) staff that work in the community’s Traditions Memory care unit had concerns regarding the treatment of the residents by staff. All six (6) staff revealed that even though they did not witness the alleged incident between Resident 1 and Staff 1, they have observed similar behavior from staff including S1. Staff revealed they have observed staff tell residents, “Oh, I’m busy, I’ll come later” when asked for assistance, or have heard staff including S1, yelling at R1, “You need to stand up, we are not picking you up,” in passing. Other staff revealed that various residents are ignored, staff pretends to not hear residents when asked for assistance, one resident is heard yelling for help and staff does not check on them because it is a behavior of the resident. It was also revealed that staff have been observed arguing with the residents. Additionally, staff revealed that concerns have been voiced to management, however nothing gets done. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Dec 23, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jan 3, 2025

Personal Rights. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff,. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when 6 out of 10 staff are voicing concerns regarding the treatment of the residents by staff which poses an immediate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: ED agreed to ensure all memory care staff attend a training focused on Resident Personal Rights. Facility will provide CCL with copy of training agenda as well as a sign in sheet for all staff who attended the training by 01/03/2025.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced continuance Inspection of the above-named facility. LPA was greeted by the front door receptionist and called Business Office Director (BOD) - Ricardo Viveros and Health Services Director (HSD) - Ian Gadea and explained the reason of the visit. The Administrator Kailey Vanderwall was not able to attend due to training and designated staff to sign the report. At approx. 9:30a.m. LPA Mosley conducted a tour of the physical plant with Health Services Director and Business Office Director to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was noted: Facility is a double-story residence that consists of a memory care unit, and an assisted living unit. LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced on 12/19/2023. On the initial visit on 09/28/2024 the Administrator provided a monthly fire alarm testing and inspection report done on 08/27/2024 where all smoke alarms and carbon monoxide detectors were tested and functioned properly. The last emergency disaster drill took place on 10/24/2024 and 10/31/2024 to cover both shifts and are conducted quarterly. LPA observed all required postings in the Activity Room near the entrance area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Activities observed on both units. In the Memory Care until at approx. 9:45am, morning movie was observed with about ten (10) to fifteen (15)residents in attendance. In the Assisted Living unit at approx. 11:00am. Paws for Love (therapy dog activity) was observed with about six (6) residents in attendance. Report Continued on LIC 809C... Report Continued from LIC 809... RECORDS: PERSONNEL FILES: were reviewed beginning at 10:25 a.m. for eight (8) staff including the Business Office Director, and Health Services Director. Files were reviewed for, but not limited to personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order at the time of the visit. RESIDENT RECORDS: were reviewed beginning at 11:26 a.m. for eight (8) residents. Files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were in order at the time of the visit. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. LPA obtained the following documents - Resident roster and Staff roster. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Nov 6, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 9:15 a.m. Upon arrival LPA were greeted by front door receptionist and explained the reason for the visit and to call their administrator. LPA met with Lace Szelesteywoodfi, Sales and Marketing Coordinator and Executive Director (ED) Kailey Vanderwall who arrived later during the visit. The reason for the visit was explained. At approx. 9:30a.m. LPA Mosley conducted a tour of the physical plant with Sales and Marketing Coordinator to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was noted: Facility is a double-story residence that consists of a memory care unit, and an assisted living unit. LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced on 12/19/2023. The Administrator provided a monthly fire alarm testing and inspection report done on 08/27/2024 where all smoke alarms and carbon monoxide detectors were tested and functioned properly. The last emergency disaster drill took place on 07/26/2024 and conducted quarterly. LPA observed all required postings in the Activity Room near the entrance area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Activities observed on both units. In the Memory Care until at approx. 9:30am, morning exercise was observed. In the Assisted Living unit at approx. 11:15am. painting was observed. Report Continued on LIC 809C... Report Continued from LIC 809... Kitchen: During the facility tour, at 9:56am the kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are available for residents in the dining area. Knives are stored and inaccessible to residents. Refrigerator and food pantry were checked for proper labels and expiration dates. Bedrooms: During today’s visit from approx. 10:01am to 10:45am, LPA observed eight (8) randomly selected resident bedrooms, of which five (5) in Assisted Living and three (3) in Memory Care. The resident bedrooms were properly furnished with at least one chair, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Restrooms: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water measured between 107.1 – 119.9 degrees Fahrenheit all within the required range. Common Areas: These included the beauty salon, library, activity room, theater, fitness center, bistro, and dining areas in assisted living and memory care units. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Fireplaces were properly screened. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents in both, the memory care unit courtyard and the assisted living courtyard. Parking is available for residents and visitors. Infection Control / Emergency disaster planning: During today’s visit the LPA Mosley reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures as it pertains to infection control are adequate. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. All records were in order. Report Continued on LIC 809C... Report Continued from LIC 809... Interviews: LPA conducted six (6) resident interviews from approx. 10:20am- 11:10am and six (6) staff interviews from approx. 11:15am- 11:40am. MEDICATION AUDIT: There are two (2) medication rooms located on each side of the facility. Med Techs distribute medication at the appropriate times to residents in care. Medication audit for five (5) residents was conducted. Three (3) in the Assisted Living Unit and two (2) in the Memory Care Unit. The following was observed. The medications were stored in the medication room in carts, both were locked and inaccessible to the residents. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. No errors observed during review. Due to time constraints the LPA will return to complete the annual at a later date. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. LPA obtained the following documents - Resident roster, LIC 500, and copy of the Limited Liability insurance. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 28, 2024

Allegation investigated: Staff did not notify resident's responsible party of an incident Staff did not communicate with resident's family regarding increase in medication

Licensing Program Analyst (LPA) Valeria Cownay conducted an unannounced subsequent complaint visit to the above facility. The purpose of the visit is to deliver final findings for a complaint initiated by LPA Z. Chochian on 09/13/2023. Upon arrival LPA met with Excecutive Director, Kailey Vanderwall, and the reason for the visit was explained. On 09/05/2023, Community Care Licensing Division (CCLD) received a complaint with the above allegations. On 9/13/2023, LPA Z. Chochain conducted the initial visit. During the visit, between 12 p.m. – 3 p.m. LPA reviewed resident records, and interviewed staff and residents. Continued on LIC 9099 Substantiated Continued from LIC 9099-C Following is a summary of the investigation findings: Regarding allegation, “Staff did not notify resident’s responsible party of an incident” – it was alleged that Resident #1 (R1) sustained a fall at the facility on June 22, 2023, a week after admission and the responsible party was not informed. Staff interviewed revealed that R1 was admitted on 06/13/2023 and did sustain two (2) falls on or about 06/22/2023 and another in 08/23/2023. Staff interviews and records reviewed confirmed that the 06/22/2023 fall was not reported to the responsible person or the department. Based on the above information gathered, there is sufficient evidence to support the allegation of “Staff did not notify resident’s responsible party of an incident”. Therefore, the allegation is deemed SUBSTANTIATED at this time. Regarding allegation, “Staff did not communicate with resident's family regarding increase in medication” – Information was received that facility staff requested a medication change from R1’s doctor without obtaining consent from R1’s responsible party. Records reviewed and interviews conducted with staff on 09/13/2023 revealed that between 6/24/2023-8/24/2023, R1’s was exhibiting behavioral issues which was reported to the doctor and therefore the seroquel medication was increased. Staff interviewed and records reviewed confirmed that R1’s seroquel medication was increased from 50mg to 75mg then to 100mg. Interview with staff revealed that R1’s change in condition since move-in and medication changes were not communicated to R1’s responsible person. Based on the above information gathered, there is sufficient evidence to support allegation “Staff did not communicate with resident's family regarding increase in medication”. Therefore, the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies was cited (refer to LIC 809-D): Exit interview conducted. A copy of the report and appeal rights provided. Continued from LIC 9099 Regarding allegation, “Staff did not seek medical attention for a resident in a timely manner” - The complainant alleged that Resident #1 (R1) was observed with a swollen arm and staff did not seek timely medical attention. Interview with staff and record reviewed confirmed that staff were notified that R1’s right arm was swollen by R1’s responsible person on 07/17/2024 and a tele-visit was conducted with R1’s doctor. Staff interviewed reported that prior to 7/17/2023, R1’s arm was not observed to be swollen. Following the tele-visit on 07/17/2023, R1’s doctor order an x-ray; which was conducted at the facility once the order was approved. X-ray of R1’s arm did not reveal any issue. R1 was a resident in the memory care unit and has since passed away. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Staff did not seek medical attention for a resident in a timely manner” is deemed UNSUBSTANTIATED at this time. Regarding allegation, “Resident hygiene needs not met” - It was alleged that R1 was not cleaned up after a bowl incident (date unknown) and was observed with dry feces on the hand the following day. Staff interviewed denied the allegation and expressed that if a resident is in the room resident is checked on at least every two hours by staff. Staff interviewed reported that residents are not left unattended and are checked on and cleaned regularly. Staff denied allegation and stated that resident are kept clean and odor free. Staff expressed that resident do have accidents and are cleaned immediately when observed. Facility common areas, and random resident rooms were toured in the assisted living and memory care on 9/13/2023, and 10/24/23. During these visits, residents and common areas did not observe to be unkept. R1 was a resident in the memory care unit and has since passed away. Based on the above gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Staff leaves residents unattended” is deemed UNSUBSTANTIATED at this time. Continued on LIC 9099-C Continued from LIC 9099-C Regarding allegation, “Staff are taunting resident” - Information was received that during the firsts two weeks of move-in R1 was observed having a volatile episode and “nurses” (names unknown) observed laughing at R1. Random staff interviewed denied witnessing any “nurses” laughing at or taunting R1. No other witnesses to the alleged was reported. Interview was attempted with random resident in the memory care unit however residents were unable to effectively communicate with LPA due to loss of level of cognitive abilities. A few random residents who were greeted by LPA did express that they like the staff and are not mistreated. R1 was a resident in the memory care unit and has since passed away. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Staff are taunting resident” is deemed UNSUBSTANTIATED at this time. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Sep 27, 2024 · control 29-AS-20230905101021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Oct 11, 2024

Personal Rights of Residents(a) Residents in all residential care facilities for the elderly...following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services...This requirement is not met as evidenced by: Based on record review and interviews, licensee did not comply with the above section by failing to inform R1 Responsible party of any change in condition or care needs related to R1, which is a potentialthe state’s words, verbatim · CDSS document, Sep 27, 2024

Plan of correction: Licensee agreed to inform responsible pary of any change of condition for all resident in care. Licensee will submit a statement of understanding of regulation cited by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 11, 2024

Reporting Requirements: (a) Each licensee shall... reports as the Department may require,...(1)A written report shall be submitted... person responsible...This requirement is not met as evidenced by: Based on interviews and record review, licensee did not comply with the above section by failing to report incidents to the Department and the responsible party involving R1, which is a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 27, 2024

Plan of correction: Licensee agreed to submit an incident report each time an event involving residents or staff occurs to CCL and responsible parties. Licensee will submit a statement of understanding of regulation cited by POC due date.

Allegation investigated: Facility staff failed to provide an appropriate level of supervision which resulted in Resident #1 (R1) being sexually assaulted by Resident #2 (R2). Facility staff failed to provide an appropriate level of supervision which resulted in Resident #1 (R1) being physically assaulted by Resident #2 (R2).

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Chochian met with Executive Director Christopher Andersen and explained the reason for the visit. On 08/31/2023, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that facility staff failed to provide an appropriate level of supervision which resulted in Resident #1 (R1) being sexually and physically assaulted by Resident #2 (R2). The complaint investigation was assigned to the Community Care Licensing Division (CCLD) Investigations Branch (IB) Investigator Douglas Real. On 09/01/2023, between 10:18 a.m. and 12:06 p.m., LPA Teresa Camara conducted an initial complaint visit. During the visit, the LPA met with the ED and requested records. At 11:17 a.m., the LPA reviewed and obtained pertinent records. (Continue to LIC9099c.) Unsubstantiated Investigator Real conducted interviews on 09/21/2023, from approximately 11:30 a.m. to 2:30 p.m., with the Business Office Director and residents; and on 10/24/2023 with staff. Additionally, investigator Real reviewed facility file documents related to R1 and R2, and contacted the Oxnard Police Department who did not investigate the matter after it was determined no crime occurred and no police report was generated. A review of R1’s physician report, dated 10/28/2021, indicates a primary diagnosis of dementia, psychosis, and hypertension. Mental conditions are listed as confused, disoriented delusions at times. R1 needs stand-by assistance with all activities of daily living. A review of R2’s physician report, dated 06/14/2021, indicates a primary diagnosis of Parkinson’s disease. No dementia or mild cognitive impairment was noted. R2 has the capacity for all self-care needs and is able to store and administer their own medications. On 03/06/2020, R1 and R2 were admitted to the assisted living section of the facility. On 11/30/2022, when R1’s needs changed, R1 was admitted to the memory care section of the facility. The investigation revealed that R1 and R2 have been married for 53 years. R2 has dinner with R1 in the memory care section of the facility every night and after dinner they go back to R1’s room where they spend time together until R1 goes to bed. According to the Business Office Director, they witnessed R1 and R2 together in bed sometime in June 2023. Sometime between 6:00 p.m. and 6:30 p.m., a staff requested the director to meet them at R1’s room. Through the door they could hear R1 talking with R2 and heard R1 say “I’m not comfortable”. The director was not sure of the context of the statement, so they entered the room and observed R1 and R2 in bed and covered with a sheet. The director asked R1 if they were okay and R1 responded “yes, I’m okay.” The director did not observe any cuts or injuries on R1’s arms or anywhere else on R1’s body. R1 did not have any concerns with R2 being in the room and wanted R2 to remain with R1 in the room. R1 did not report any problems or concerns to the director and wanted them to leave. R2 also asked them to leave, the director and the staff then left after determining nothing was wrong. The resident care notes dated 06/21/2023 and 06/22/2023, document that R1 and R2’s resident representative was contacted to discuss intimacy, safety and privacy. R1 and R2’s resident representative was supportive of R1 and R2 being together alone in R1’s room and had no concerns. The resident care notes further document that on 06/13/2023, R1 was noted to have a skin tear to lower left arm and treated by staff. Home health services was contacted and redressed the wound on 06/16/2023. (Continue to LIC 9099c.) The interviews conducted with R1, R2, other residents and staff during the complaint investigation did not indicate R1 suffered any physical or sexual abuse from R2. R1 and R2 denied the allegation. R1 and R2’s resident representative was supportive of R1 and R2 being together alone in R1’s room and had no concerns. The residents interviewed felt safe in the facility and had no complaints or problems to report. No one reported any neglect or lack of care or supervision. The facility staff denied the allegation and felt the level of care provided to the residents was appropriate. The information and evidence obtained did not sufficiently support the allegation, therefore the allegation “Neglect/Lack of Supervision: Facility staff failed to provide an appropriate level of supervision which resulted in Resident #1 (R1) being sexually and physically assaulted by Resident #2 (R2)” is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, Apr 18, 2024 · control 29-AS-20230831162554

Allegation investigated: Due to lack of supervision, resident fell, resulting in injury.

Licensing Program Analyst (LPA) Zabel Chochian conducted unannounced subsequent visit to the above listed facility. The purpose of today’s visit is to conclude an investigation initiated by LPA Kelly Dulek on 12/14/2022. During today’s visit, LPA met with Executive Director Chris Andersen and the purpose of the visit was explained. Entrance interview conducted. During the initial 10-day visit on 12/14/2022, LPA Dulek interviewed staff from approximately 1:20 PM to 1:45 PM, toured the facility with the Executive Director and Memory Care Director at approximately 1:45 PM, and obtained copies of pertinent documents. A subsequent visit was conducted by LPA Zabel Chochian on 2/09/2023, additional staff were interviewed from approximately 11:30 AM to 3:45 PM; LPA toured the Memory Care at approximately 4pm with staff and residents were observed and interviews were attempted during the tour. Additional interviews were conducted on 11/1/2023, 11/13/2023 and 12/06/2023 with potiential witnesses. (Continue to LIC9099c) Substantiated It was alleged that due to lack of supervision, Resident #2 (R2) fell and sustained an injury. It was further reported that R2 sustained an injury to the right eye and a fracture in the right shoulder. This allegation was previously referred to Community Care Licensing Division’s Investigation Branch (IB) and assigned to Investigator Douglas Real (Complaint Control # 29-AS-20220906140504). The Department issued Substantiated findings on 02/09/2023. Deficiencies and civil penalties were also issued at the time of the visit; therefore, no citations will be issued during today’s visit. Exit interview conducted and copy of report issued. Regarding allegation, “Staff handled resident roughly, resulting in injury” – The reporting party alleged that staff #1(S1) handled Memory Care residents roughly. It was alleged that S1 pushed Resident #1’s (R1s) wheelchair very hard and R1s shin hit the wheelchair's footrest, which caused a skin tear (date and time of the alleged incident is unknown). It was also alleged that R1 is often bruised or with small unexplained skin tears. Interviews conducted and documents reviewed reflected R1 would be agitated and combative when staff would try to assist; therefore, staff would let R1 calm down and would go back at a later time to assist. Interviews further reflected that staff did not force R1 with anything. Staff also mentioned that R1 would bruise easily; however, did not recall specific injury incident as alleged. LPA attempted to contact Staff #1 (S1) on 11/03/2023 at 3 PM and on 11/6/2023 at 10 PM and 2 PM, however was unsuccessful. Additionally, on 11/02/2023, at approximately 3:30 PM, LPA contacted the Reporting Party (RP) for additional details; however, RP did not have any further details to provide. Moreover, documents reviewed did not reflect the alleged incident/injury. LPA also attempted to interview random residents in the memory care unit, however they were unable to communicate due to cognitive decline. Potential witness/families of residents interviewed did not reveal any rough handling or mistreatment by staff towards residents. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Staff handled resident roughly, resulting in injury” is deemed UNSUBSTANTIATED at this time. Regarding allegation, “Staff do not ensure resident receives meals” - The complainant alleged that staff do not get R1 up for breakfast or lunch; staff often leave R1 in bed hungry until 01:00 PM. Staff interviewed reported that R1 was receiving hospice services, did not have an appetite and usually did not get up for breakfast. Therefore, R1 was provided with a meal when R1 was awake and ready to eat. Staff interviewed denied the allegation that “staff do not ensure resident receives meals”. Staff reported that all residents are provide three (3) meals a day including snacks in between meals. During initial visit and subsequent visits to the facility, LPA observed the dining room area in Memory Care and observed residents eating. Potential witness/families interviewed did not express any concern with residents receiving meals. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Staff do not ensure resident receives meals” is deemed UNSUBSTANTIATED at this time. (Continue to LIC9099c) Regarding allegation, “Staff leaves residents unattended” – It was alleged that S1 leaves Resident #3 (R3) unattended for 2-hour time periods. It was further reported that staff take resident out in wheelchairs in front of the television then not check on resident for at least 2 hours at a time. Interviews with staff revealed that residents are provided with time to watch television and are checked multiple times throughout the day by staff on the floor. Staff reported that residents are within eyesight when in the common area. Staff stated that if a resident is in the room resident is checked on at least every two (2) hours by staff. Staff interviewed reported that residents are not left unattended and are checked on regularly. Potential witnesses interviewed stated that they have observed staff in the common areas of the memory care unit watching residents. It was reported that staff are observed on the floor in the common areas throughout the day. No issues or concerns were reported at the time of the interviews. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Staff leaves residents unattended” is deemed UNSUBSTANTIATED at this time. Regarding allegation, “Staff do not ensure residents receive showers” - Information was received that memory care unit residents are not being showered regularly. It was alleged that some of the staff aren't offering showers to the residents and are just writing that residents refuse to shower so they don't have to shower the residents. Staff interviewed denied the allegation and reported that showers are provided to residents and if the resident is combative and or refuse, they will not force the resident to shower. Staff interviews revealed that refusal of any services including, but not limited to, shower refusal is always documented. Staff denied the allegation of falsely documenting shower refusal for any resident. Staff reported if a resident constantly refuses to shower it is reported to management and family. During the initial and subsequent visits LPAs toured the facility’s memory care unit. Residents in the common area observed appeared to be clean and dry. Sample shower logs observed during initial and subsequent visit documented residents shower refusal. Other records reviewed at the facility revealed that hospice residents receive showers from the hospice agency twice a week. Potential witnesses interviewed did not report any unmet hygiene needs of residents. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Staff do not ensure residents receive showers” is deemed UNSUBSTANTIATED at this time. Exit interview conducted/No citations issued/ A copy of report was provided.the state’s words, verbatim · CDSS document, Dec 7, 2023 · control 29-AS-20221205110809

Allegation investigated: Staff video recorded resident without permission. Staff mocked resident. Staff speak to residents disrespectfully.

Licensing Program Analyst (LPA) Zabel Chochian conducted unannounced subsequent visit to the above listed facility. The purpose of today’s visit is to conclude an investigation initiated by LPA Chochian on 02/09/2023. During today’s visit, LPA met with Chris Andersen, Executive Director (ED) and the purpose of the visit was explained. Entrance interview conducted. During the initial visit, LPA met with ED at approximately 09:30AM. The reason for the visit was explained. ED provided copies of pertinent documents for LPAs review. During the initial visit, LPA also conducted interviews with staff from approximately 11:30AM to 3:45PM. LPA and Sheila Ramirez, Memory Care Director toured the Memory Care at approximately 4pm. Resident interviews were also attempted during tour. Following is a summary of the investigation: Allegations “Staff video recorded resident without permission and Staff mocked resident” – Information was received that, about a month or two ago a video recording was seen on cell phone of Staff #1 (S1) and Staff #2 (S2) with Resident #1 (R1). Unsubstantiated According to reporting party (RP), in the video, S1 and S2 were mocking and ridiculing R1. This was brought to the attention of the Executive Director and Memory Care Director. RP was unsure whose cell phone it was recorded on or if the video was posted. The video recording was shown to staff in the facility's break room. The video was taken in the memory care unit in R1’s bathroom. Both S1 and S2 were seen on the video with R1, making fun of R1 in the recording. LPA interviewed six (6) staff on 2/9/2023 between 11:30AM to 3:45PM. Conflicting information was provided by staff. S1 and S2 denied that they ever recorded R1 in the shower or that they ever mocked and ridiculed R1. Both S1 and S2 reported that they do take pictures with residents and record sometimes with families consent to share with families. Two out of the six staff interviewed reported seeing this video. One staff reported it was a video and audio recording and S1 and S2 were making fun of R1, mocking and ridiculing R1 in the video. Another member of staff reported that they did see a video however there was no audio. This staff stated that R1 was seen in the video with back to the camera getting in the shower. Staff stated that the only thing you can see was the back of R1’s head nothing else. Four other staff named as witnesses interviewed denied ever seeing any video recording in the break room of R1. LPA discussed this allegation with the ED. Furthermore, it was explained that the alleged video recording was reported by concerned staff. An internal investigation was conducted, and staff were interviewed by the ED. Staff interviewed denied the allegation. No staff came forward about seeing this video in the facility break room to corroborate the allegations. ED mentioned that a meeting was held with all memory care unit staff regarding facility house rules, policies and procedures were reviewed. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegations or that a violation occurred; therefore, the above allegations “Staff video recorded resident without permission and Staff mocked resident” is deemed UNSUBSTANTIATED at this time. Regarding allegation “Staff speak to residents disrespectfully” – RP expressed concerns about the Memory Care staff at the facility. RP reported that about a week ago, resident #2 reported to RP that S3 called R2 an "idiot." RP claims that R2 is cognitively aware, and this wasn’t the first time this resident reported verbal abuse by this same staff. RP stated that this was reported to the Memory Care Director, but nothing came of it. RP has heard the same staff last year in the dining room speaking to residents in rude condescending way and it was reported to the former Director and Health Services Director (HSD) at the time. RP also stated that the memory care unit HSD, S1 and S2 are also often disrespectful and rude. Staff interviews conducted revealed conflicting statements. Staff interviewed denied the allegation. (Continue to LIC9099c) LPA attempted to interview residents in the memory care unit. Random residents approached did not respond to LPA’s greeting to converse with LPA. Residents did not comprehend basic questions asked. LPA was able to interview a visitor at the facility on 02/09/2023 and they reported that they are at the facility at least 2-3 times a week and have not observed any staff to be disrespecting or rude with residents. Attempt was made to reach former staff on 11/1/2023, 11/13/2023 and 11/14/2023. Other potential witnesses interviewed on 11/13/2023 expressed that they like the facility and they have not observed/witness any staff to be disrespectful or rude to residents in care. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Staff speak to residents disrespectfully” is deemed UNSUBSTANTIATED at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 7, 2023 · control 29-AS-20230201102747

Type of visit: Required - 1 Year

At 09:30 a.m. Licensing Program Analysts (LPA) Jenny Olson arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff and informed them of the reason for the visit. Administrator arrived shortly after. At 10:45 a.m. LPA conducted a tour of the physical plant with Administrator to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was noted: Facility is a double-story residence that consists of a memory care unit, and an assisted living unit. LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced on 12/20/2022. The Administrator provided an annual fire alarm testing and inspection report done on 07/06/2023 and 10/09/2023 where all smoke alarms and carbon monoxide detectors were tested and functioned properly. LPA observed all required postings in the Activity Room near the entrance area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Kitchen: During the facility tour, the kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are available for residents in the dining area. Bedrooms: During today’s visit, LPA observed ten (10) randomly selected resident units. The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. At 11:32 a.m. LPA observed Clorox wipes unlocked under the sink in Memory Care RM 114. The room was locked but the Clorox wipes were accessible to Resident 1 (R1). In assisted Living At 11:47 a.m. LPA observed Lysol Disinfectant spray, Clorox wipes, 409, and beach cleaner in RM139. The room was locked but accessible to Resident 2 and 3. At 11:55 a.m. Continued on LIC809-C. The room was locked but accessible to R4. LPA observed disinfecting wipes and Lemon Lift Heavy Duty Kitchen and Bathroom cleaner with Bleach in RM222. At 12:07 pm LPA observed cleaning supplies in RM210. The room was locked but accessible to R5. Administrator immediately locked up R1’s Clorox Wipes with Memory Care Director and informed Assisted Living residents they would have to lock up their disinfectants and cleaning solutions with staff or give to their family members. Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid shower floors in all bathrooms. Out of the ten (10) bathrooms observed, one (1) toilet and sink required cleaning. Upon observation, staff cleaned the areas. Water temperature measured in the restrooms ranged between 105.9 degrees Fahrenheit and 119.0 degrees Fahrenheit. Common Areas: These included the beauty salon, library, activity room, theater, fitness center, bistro, and dining areas in assisted living and memory care units. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Fireplaces were properly screened. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents in both, the memory care unit courtyard and the assisted living courtyard. Parking is available for residents and visitors. Infection Control: The community's policies and procedures pertaining to infection control were adequate. Record Review: A review of facility files was initiated. LPA Olson reviewed five (5) of ninety seven (97) Staff files. Out of the five files reviewed, LPA Olson identified one staff, (S1) did not have a criminal record clearance. LPA Olson reviewed five (5) out of eighty-seven (87) resident files. All files were complete. MEDICATION AUDIT: A medication audit for three (3) of five (5) residents was initiated and the following was observed. The medications were stored in the medication carts, which was locked and inaccessible to the residents. During resident audits, the LPA observed various medications with the start date not properly documented on the centrally stored medication and destruction log. Staff documented the correct start date upon observation. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report, appeal rights and civil penalty was provided.the state’s words, verbatim · CDSS document, Oct 24, 2023

The state marks this report as 8 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.