Oakmont of San Jose

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Administrator, Kippie Castronovo and stated the purpose of today's visit. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai observed 3 day of emergency food and water supply in the basement. LPA Rai toured the facility to include 7 resident rooms, common areas, dining room, kitchen and garage/basement. 7 Out of 7 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The delayed egress doors in the Memory Care Unit and wander guard are in working condition. The hot water temperature in the bathroom sinks ranged from 113.3 - 115.5 degrees F. Fire extinguisher was observed and inspected on 05/30/2025. Facility smoke detectors and sprinkler system were inspected by third party vendor on 11/7/2025 and the report stated the systems are in working condition. The last disaster drills were conducted on 02/03/2026 and 03/08/2026. LPA Rai observed a complete first aid kit at the facility. LPA Rai reviewed facility records for 7 staff and 7 residents. LPA Rai reviewed resident medications and central stored medication records. No deficiencies were cited per California Code of Regulations, Title 22. Technical Violation was provided. This report was reviewed with Administrator, Kippie Castronovo and a copy of the report was provided. LIC 858 and LIC 859 were provided.the state’s words, verbatim · CDSS document, Apr 29, 2026

Allegation investigated: Facility does not ensure facility elevators are maintained in good repair Facility administrator and staff are falsifying staff training records Facility is not conducting emergency drills

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to deliver the findings for the above allegations. LPA met with Executive Director (ED), Kippie Castronovo. LPA stated the purpose of the visit. On 1/7/2026 the Department received a complaint. On 1/8/2026 the initial complaint investigation was conducted. It was alleged that facility does not ensure facility elevators are maintained in good repair. On 1/7/2026 the Department interviewed the Reporting Party (RP). RP states the facility elevators were broken down on 12/25/2025 and repaired and working on 1/2/2026. RP states the elevators “break but they are repaired but then break again.” Page 1 of 3 Unfounded LPA observed the main and service elevator permits with a date of inspection of 12/5/2023, and an expiration date of 12/5/2024. The permits were issued by the State of California, Department of Industrial Relations, Division of Occupational Safety & Health. On 1/8/2026 the Department interviewed the Administrator (ADM) Kippie Castronovo, 5 Staff (S1 to S5), and 3 Residents (R1 to R3). ADM states the two facility elevators (main and service) ‘have issues.’ ADM states the facility main elevator was out of service sometime in late December 2025 for approximately 8 days. ADM states the main elevator was repaired and operational after this incident in December 2025. ADM states the main elevator broke down again in early January 2026. ADM states maintenance is notified any time the elevators are not working. On 1/8/2026 the Department interviewed 5 Staff (S1 to S5). 5 out of 5 staff he/she is aware of the facility elevators breaking down. 3 out of 5 staff state the facility repairs the elevators any time the elevators are broken down. 2 Out 3 did not provide additional information. On 1/8/2026 the Department interviewed 3 Residents (S1 to S3). 3 Out of 3 residents state he/she is aware of the facility elevators not working sometimes. 2 Out of 3 residents state the facility repairs the elevators when they are broken down. R3 did not provide additional information. Review of facility elevator service logs, a ‘Callback’ was placed on 1/3/2026 at 12:54PM, with ‘End Date’ of 1/3/2026 1:30PM. The log notes labor hours as 1 hour and 15 minutes for the repair. LPA also observed 'Callback' for 12/17/2025 at 7:59AM with 'End Date' of 12/17/2025, with time of 30 minutes, and labor 45 minutes, a 'Callback' on 12/18/2025 at 6:29PM, with an 'End Date' of 12/18/2025 at 8:15PM, with 4 hours and 45 minutes of regular time, 45 minutes of labor. Facility administrator and staff are falsifying staff training records It has been alleged that that facility ADM and staff are falsifying training records. On 1/7/2026 the Department interviewed the Reporting Party (RP). RP states the ADM falsifies staff training records so ‘she would not have a bad number, reflect bad on her as a manager.” RP states the ADM “made” him/her participate in falsifying staff training documents for the past 7 months. Page 2 of 3 On 1/8/2026 the Department interviewed 5 Staff (S1 to S5). 4 out of 5 staff he/she completes his/her own training online. 4 Out of 5 staff state he/she logs into the training using his/her own personalized login information. LPA was unable to ask S5 this question due to S5 being called away to assist a resident. LPA reviewed 7 random staff training records. 7 Out of 7 staff trainings document “hours, dates, modules, status, grade, completion date.” 2 Out of 7 staff training records note individual user information for staff. 5 Out of 7 staff training records only note the staff name. Staff training included but not limited to dementia care, essential resident rights, fire safety. Facility is not conducting emergency drills On 1/7/2026 the Department interviewed Reporting Party (RP). RP states he/she observed the ADM tell another staff member that she ‘falsified’ the emergency training records. RP states this occurred about 1 or 2 months ago. On 1/8/2026 the Department interviewed 5 Staff (S1 to S5). 1 Out 5 staff state he/she has participated in an emergency drill in 2025. 3 Out of 5 staff stated he/she has not participated in an emergency drill but also stated he/she was not sure if they participated in an emergency drill. S4 states he/she was not sure because he/she only works 3 days a week at the facility. LPA was unable to ask S5 this question due to S5 being called away to assist a resident. Review of facility emergency drill logs note the facility conducted emergency drills each month from January 2025 to December 2025, with an in-service sign in sheet signed by facility staff. This agency has investigated the complaint alleging facility does not ensure facility elevators are maintained in good repair, facility administrator and staff are falsifying staff training records, facility is not conducting emergency drills. We have found that the complaint was UNFOUNDED meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies were cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with Executive Director (ED) and a copy of this report was provided. Page 3 of 3 END OF REPORTthe state’s words, verbatim · CDSS document, Jan 28, 2026 · control 26-AS-20260107123034

Allegation investigated: Facility staff did not obtain criminal record clearance

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a complaint investigation visit. LPA met with Administrator (ADM) Kippie Castronovo. LPA stated the purpose of the visit. On 1/7/2026 the Department received a complaint with the above allegation. It has been alleged that the facility staff did not obtain criminal record clearance for staff members. On 1/7/2026, the Department interviewed Reporting Party (RP). RP states there is one staff member who works in the kitchen who does not have a criminal background clearance. Page 1 of 2 Unfounded On 1/8/2026 the Department toured the facility and observed 18 staff members. LPA spoke with 18 staff members and verified on the Licensing Information System facility personnel report that all 18 staff members had obtained a California Criminal Background Clearance. LPA reviewed 2 staff files. LPA observed 2 Out of 2 staff had obtained a criminal background clearance. This agency has investigated the complaint. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, Jan 8, 2026 · control 26-AS-20260107123034

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 inappropriately touched a resident while in care Staff pushed a client while in care Staff inappropriately restrained a resident Staff allow a resident to be soiled while in care Staff do not ensure the resident's toilet is being flushed

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the finding for the above allegation. LPA met with Executive Director, Kippie Castronovo. On 01/23/2025, the Department received the complaint. On 01/24/2025, the initial complaint investigation was conducted. The following documents were obtained for this allegation to include resident (R1)’s physicians report, shower schedule, resident assessment, physician order routine medications, charting notes, police report, and correspondences. It was alleged that staff (S1) had inappropriately touched resident (R1) in various places, pushed R1, and inappropriately restrained R1 by pinning R1 down to his/her bed and getting on top of him/her. It was stated that another staff (S2) witnessed the incident and did nothing to help. Page 1 of 4. Unsubstantiated On 01/14/2025 (Tuesday) or 01/15/2025 (Wednesday) at approximately 2215 hours, R1 reported that S1 grabbed him/her by the neck, took off his/her clothes, touched him/her in private areas while S2 stood and watched. R1 stated that S1 and S2 were going to give him/her a shower when the incident occurred. However, according to staff and R1’s shower schedule, R1 is assisted with showers on Monday and Friday between 1500 – 1600 hours. Law enforcement conducted an investigation and interviewed R1 and S1. It was noted that R1 did not recognize or know the names of the staff who were part of the incident. S1 denied the allegations. S1 states that there was an incident where S1 and S2 checked on R1 in his/her room and found R1 laying too close to the edge of his/her bed. S1 and S2 tried to help R1 back up to his/her bed, but R1 become irritated and aggressive. S1 and S2 decided to leave R1’s room and stated nothing else happened. Based on review of the law enforcement records, R1 did not have any visible injuries and declined a Sexual Assault Forensic Exam (SAFE). No arrests were made by law enforcement. R1 was interviewed. Based on interview with R1, it was stated that S1 and S2 came into his/her room to give him/her a shower. R1 states that S1 yelled at him/her, grabbed his/her neck, and laid on top of him/her. R1 stated that S1 touched him/her all over his/her body included the chest and arm area. R1 stated the touching occurred over clothes and a blanket. R1 states that S1 did not touch his/her private part and only touched his/her lower body. R1 stated to have kneed S1 and both staff left the room. S1 and S2 were interviewed. Based on staff interviews, both staff denied the allegations of inappropriately touching and handling R1. S1 and S2 states that they went to R1’s room to check on his/her diaper and found R1 laying on the edge of the bed. S1 and S2 tried to move R1 back to the middle of the bed when R1 became upset and refused assistance. S1 states that that he/she may have touched R1 when trying to move him/her but not in an inappropriate area like the private areas. Page 2 of 4. S2 denied the observation of S1 touching R1 inappropriately, and states that S1 only touched the back of R1’s shoulder while they were trying to prevent R1 from slipping off the bed. It was stated that S1 was wearing a blanket while being moved. S2 states that R1 was upset with S1 because S1’s voice was too loud. S1 and S2 never mentioned any other incidents occurring to include pushing R1 and inappropriately restraining R1 in bed. S1 and S2 stated they had only assisted R1 by moving R1 back to the middle of the bed to prevent R1 from falling. Due to R1 becoming upset and refusing assistance, S1 and S2 left the room and were not able to change R1’s diaper. S1 and S2 stated they never mentioned anything to R1 about a shower. S1 states that he/she never gave R1 a shower because R1 prefers to be assisted by the same gender staff. Based on staff interviews, it was stated that R1 has made similar allegations at another facility. It was also stated that R1 previously reported that he/she saw male staff in his/her room during the nocturnal shift, but only female staff worked during that shift. Staff members interviewed described S1 as a good worker and good with the residents. Staff never observed any inappropriate behaviors from S1 towards the residents nor has there been any previous complaints against S1 acting inappropriately towards the residents. To avoid any further issues with R1, S1 was instructed not to go to R1’s room going forward. It was alleged that staff allowed a resident (R1) to be soiled while in care as R1 was left in his/her own feces in bed. The length of time R1 was left in his/her own feces was unknown. 6 residents were interviewed. Based on resident interview, 5 out of 6 residents stated that they have never been left soiled for an extended period of time. 1 out of 5 residents stated that he/she was left soiled for 4 hours but was unable to recall more information as to when and what time it occurred. Page 3 of 4. Based on interview with R1, R1 denied ever being left soiled while in care of the facility. 4 staff members were interviewed. Based on staff interview, it was stated that staff check on the residents and change their undergarments as needed or as often as 1-2 hours to ensure the residents are kept dry and comfortable. 4 out of 4 staff denied the observation of a resident who was left soiled for an extended period of time. 4 out of 4 staff denied the observation of R1 left soiled. 4 out of 4 staff states that they will always assist residents if they know and observe that they are soiled. It was alleged that staff do not ensure resident (R1)’s toilet is being flushed. 6 residents were interviewed. Based on resident interview, it was stated that if the resident is able toilet on their own, then the resident would flush their own toilet. Based on interview with R1, R1 states that he/she is capable of using the toilet on his/her own and flushes his/her own toilet after use. Another resident (R2) stated that sometimes the resident or staff would forget to the flush the toilet after use, however, if it’s brought to the staff or resident’s attention the toilet would get flushed. On 05/29/2025, LPA interviewed 6 residents inside their apartments. 5 out of 6 of the resident’s toilets were observed flushed. 1 out of 6 residents toilets was not flushed and contained urine and toilet paper, however this resident is independent with toileting. No foul orders observed. 4 staff members were interviewed. Based on staff interview, R1 usually flushes his/her own toilet. 4 out of 4 staff members stated that if staff were to observe that a resident’s toilet is not flushed, then staff would assist in flushing the toilet. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegations may have happened and/or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Kippie Castronovo and a copy of the report was provided. Page 4 of 4.the state’s words, verbatim · CDSS document, May 29, 2025 · control 26-AS-20250123100945

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Santino Fortes conducted an unannounced annual inspection, and met with Marketing Director (MD) Jan Krum and Val Baldugo (Acting Executive Director AED). MD stated facility has 19 staff and 66 clients. LPA toured the facility inside and out. Facility has 67 resident rooms. LPA inspected 4 resident rooms, Memory care unit, 3 Assisted living and 2 independent living rooms, 2 activity rooms, Kitchen and 2 stairwells. LPA observed residents participating in Art, exercise activities and lunch meal service. LPA observed resident rooms each with a chair, night stand, sufficient lighting and chest of drawers. Room temperature was 72.5* F. Hot water temperature was Bathroom 1- 119.8*F, Bathroom 2- 118.2* F and Bathroom 3- 119.5* F. LPA observed the first aid supplies to be complete. Smoke and carbon monoxide detectors panel was functioning properly. Fire extinguishers were serviced on 3/23/2025, 3/31/25. Staff conducted a fire drill on 12/31/2024. Restrooms observed to have non skid flooring. LPA observed 2 days perishable food supply and 7 days non-perishable food supply. Refrigerator temperature observed at 32* F and Freezer temperature 14*F. LPA observed medication storage room and carts locked and inaccessible. Knives, and cleaning product storage was locked in the main kitchen, inaccessible to clients in care. The storage and surrounding areas of the facility was inspected. Exits, stairwells and walkways were unobstructed. LPA observed 2 Stairway EVAC chairs at the top of each emergency stairwell. LPA reviewed facility records for 4 staff, 5 clients and observed to be complete. LPA reviewed 5 client’s medications, centrally stored medication records and observed to be complete. No deficiencies were cited during today's visit as per California Code of Regulations Title 22. Exit interview was conducted with AED. This report was reviewed and a copy was provided to AED for signature.the state’s words, verbatim · CDSS document, Apr 11, 2025

Allegation investigated: Facility increased resident's fees without proper notice.

On 9/13/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director, Kippie Castronovo and explained the purpose of today's visit. Regarding the allegation that facility increased resident's fees without proper notice, RP alleges that the facility did not adhere to the Admission's Agreement and engaged in a "bait and switch" scheme by increasing R1s fees right after R1 entered the facility, increased the fees without proper notice. Based on records review, facility did an initial assessment after R1 has moved in. However, there was no written notice given to the responsible party regarding this increase in rate, within 2 business days from this assessment. Therefore, based on interviews and records review and information collected, the above allegation is determined to be SUBSTANTIATED. Deficiency of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiency may result in civil penalties. A copy of this report and the Appeal Rights are provided. Substantiatedthe state’s words, verbatim · CDSS document, Sep 13, 2024 · control 26-AS-20220915105128

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.657(a) · Plan of correction due date: Sep 20, 2024

§1569.657 Rate increase due to change in level of resident care; notice (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. This was not met as evidenced by: Based on records review, the facility did not provide 2 day written notice about detailing the new rate for the charges for the new level of care.the state’s words, verbatim · CDSS document, Sep 13, 2024

Plan of correction: Licensee to submit a plan to address the submission of notices to residents/responsible parties if there is any rate change in the level of care. Licensee to submit by POC due date.

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff are not following Covid-19 protocols Staff administered unsanitary medication to resident

On 9/6/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Memory Care Director Sherry Theam and explained the purpose of today's visit. Regarding the allegation of staff are not following Covid-19 protocols, Reporting Party (RP) stated that staff member (S5) did not follow protocol by dressing in PPE and entering a room, which has PPE located in stacked containers, outside the room. S5, along with an "Agency Caregiver," stood outside the room, engaging in a conversation while the sick resident (R2) stood in the doorway. R2 was not wearing mask. Another instance mentioned was, Care Provider (S2) delivering the dinner tray to Room and did not dress in the PPE, located outside the room, prior to entering. S2 sounded raspy and sick too, and was wearing only a surgical mask, not a N95 mask to protect the Residents. S2 did not use the hand sanitizer, located outside the room, after exiting. page 1 of 2 Substantiated Based on records review, LPA Donato referred to PIN 21-38-ASC regarding masking. It states that All ASC (Adult Senior Care) residential facilities must strictly adhere to current CDPH Masking Guidance. During the time of the complaint the applicable California Department of Public Health (CDPH) Guideline, dated March 14, 2022, states that masks are required for all individuals in the following indoor settings, regardless of vaccination status. Surgical masks or higher-level respirators (e.g., N95s, KN95s, KF94s) with good fit are highly recommended, Long Term Care Settings & Adult and Senior Care Facilities. LPA Dolores was able to obtain a photo showing S2 leaving the room of R2 and wearing only mask. No other PPEs was worn or removed. LPA interviewed S5, and it was mentioned that there was an incident when a resident's family member saw S5 not wearing a mask. S5 had been eating or drinking something and forgot to put the mask on again. S5 knows masks are mandated in care facilities. Regarding the allegation of staff administered unsanitary medication to resident, RP stated that S7 dropped R1s medication on the floor next to R1s commode, picked it up, and placed it on the spoon to give to R1. During S7s interview, it was stated that the medication did not totally drop on the floor and dropped on the pants R1 was wearing. Another staff member (S6) confirmed that S7 did drop the resident’s medication and administered to the resident. In S6s interview of S7, confirmed to drop the medication, cleaned it, and gave it to R1. S6 states S7 put hand sanitizer prior to entering the room but did not perform hand hygiene inside the room prior to giving medication, then performed hand hygiene outside the room. LPA Dolores also interviewed other staff members. S1 mentioned that if a medication drops, they pick it up, report it to Health Services Director (HSD), and pop another one if it's from the bubble pack, give the clean medication to the resident, then inform the pharmacy for another tablet because they would be missing supply. They're not supposed to give it to the resident because it's dirty. Another staff member (S3) also stated that if meds spill, S3 picks it up and disposed the med in the waste bin. They'd administer new medication by popping a new one. They do not give the medication that dropped to the resident. If they pop another one, they'd inform the pharmacy, and they would send a new one. Therefore, based on interviews and records review and information collected, the above allegations are determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. A copy of this report and the Appeal Rights are provided. page 2 of 2 LPA has reminded RP that per HIPAA law, we are not able to disclose if a resident or staff have covid and that the facility is being monitored during this time. Regarding the allegation staff are not performing hand hygiene when assisting with medications, RP stated that staff member (S7) failing to sanitize her hands, or put on gloves, while administering medication R1. S2 entered the room and did not wash or sanitize his/her hands prior to touching the rim of R1s water cup. S7s fingers are touching the rim of the cup where R1 will be placing his/her lips as he/she drinks. S7 did not put on gloves either. LPA Dolores was able to interview S7 and it was stated that S7 would use hand sanitizer outside the room. S7 would enter the room and give the resident medication. LPA Dolores asked S7 if he/she would perform hand hygiene prior to administering the resident's medications and S7 states to already put on hand sanitizer outside the room. Based on records review, according to Title 22 regulation, 87470 Infection Control Requirements (a)(1)(A) Hand hygiene shall include hand washing with soap and water or using an alcohol based sanitizer or any other sanitizing method recommended by a medical professional, local health official, health department, or other research based medical authority. Based on interviews & records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. page 2 of 2 Based also on records review, according to PIN 20-13- ASC Notification To Families When A Person Tests Positive For Coronavirus Disease 2019 (Covid-19) , Upon confirmation that a person in care or facility staff member has tested positive for COVID-19, and either remains in the facility or is no longer in the facility, CCLD advises ASC licensees to provide immediate notice to families of all persons in care. The notice to all families shall not disclose any personally identifiable information or protected health information about the person who tested positive for COVID-19. Based on interviews and records review, the department has determined that that the allegation were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. Report is reviewed and copy is provided. page 2 of 2the state’s words, verbatim · CDSS document, Sep 6, 2024 · control 26-AS-20220518114814

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 13, 2024

87468.1 Personal Rights of Residents in All Facilities(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was not met as evidenced by: Based on records review, S2 was only wearing mask and no other PPEs while serving food to covid residents, S5 was not wearing mask while speaking to covid residents, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 6, 2024

Plan of correction: Licensee to submit proof of in-service training regarding infection protocols. Licensee to submit by POC due date.

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

87411 Personnel Requirements – General(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs ... This was not met as evidenced by: Based on records review & interviews, S6 administered medication that has already fallen on the floor, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 6, 2024

Plan of correction: Licensee to submit proof of in-service training regarding medication administration. Licensee to submit by POC due date.

Allegation investigated: Staff did not accord resident dignity and respect. Staff did not respect resident's personal privacy

On 8/26/2024, Licensing Program Analysts (LPAs) Grace Donato & Christine Dolores conducted an unannounced complaint investigation visit. LPA met with Executive Director Kippie Castronovo and explained the purpose of today's visit. Regarding the allegation of staff did not accord resident dignity and respect & staff did not respect resident's personal privacy, Reporting Party (RP) stated that RP sent staff member S1 and S3 requests that only essential care visits would be allowed. On 05/13/2022 at 10:00 a.m., there was knocking at the resident's (R1) apartment and RP looked through the peephole and saw S1. RP told S1 if they can please call and discuss the needs over the phone because S1 blurts things out and there's no privacy. RP did not give permission for S1 to enter and just instantly put the master key in the lock. page 1 of 3 Unsubstantiated R1 woke up when S1 entered the apartment. S1 went up to R1 and asked if R1 wanted to speak to R1s family member. R1 said yes, and S1 went down to get the iPad. S1 arrived 30 minutes later with the iPad and RP gave permission to enter the apartment. S1 observed R1 to be asleep and left. LPA Dolores interviewed three staff members. S1 mentioned that he/she knocked on the door and RP did not open the door and was told to get out of there. S1 told RP that they needed to talk to R1 because a family member wanted to FaceTime with R1, RP still did not open the door and S1 entered his master key in the lock. S1 states he/she did not forcefully opened the door and entered in the room slowly. S1 did not force or push the door open. For their (residents) privacy, they knock on the door. If they don't answer, they open the door to see if they're okay. RP said get out of here and S1 said he/she needed to talk to R1. RP questioned why they put the master key in. S1 explained that after they knock 3 times and they don't answer, they need to open the door to check on the resident. Another staff member (S2) confirmed S1s actions. S2 stated that they were coming up to R1s room with the iPad to Facetime R1s family. On the door there are notes/instructions for caregivers to knock softly. S1 knocked softly and they didn’t hear anything. After a couple of knocks they heard the RP say, “hello how can I help you?” S1 introduced himself/herself and S1 opened the door. S1 walked inside and said I have a question for R1. S2 heard S1 ask R1 a question. S1 said they’ll come back in 15 minutes. S1 didn’t forcefully push the door because when S1 opened the door, RP already said "hi how can I help you". RP can see through the peep hole of anyone at the door. S2 also added that usually whenever they go to the door, they have to knock and then introduce themselves. S2 said that what they trained to do is first knock on the door and usually wait for a hello. When it’s locked, they wait for the resident to come to the door, if they know resident is not able to get up on their own and needs help getting up, they'll use their key and open it slowly. If the resident says they’ll be right there, they’ll wait. The residents are really good about letting staff know if they want us to wait outside and they’ll be right there. page 2 of 3 Staff member (S3) stated that they never observed a staff force themselves inside a resident’s room. In assisted living they’re alert and oriented. S3 checks in with them once in a while and they'd inform if there is anything is wrong. They knock on the door for privacy. Some of the residents doesn’t like the doorbell and others do. They get to know the residents to know their preference. If they need to enter, the staff knows to just knock. After they knock, they'll introduce themselves. They don’t just barge in. They know not to do that. Based on interviews & records review, the department has determined that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. page 3 of 3the state’s words, verbatim · CDSS document, Aug 26, 2024 · control 26-AS-20220523155841

Allegation investigated: Staff engaged in a verbal altercation in the presence of resident's.

On 8/26/2024, Licensing Program Analysts (LPAs) Grace Donato & Christine Dolores conducted an unannounced complaint investigation visit. LPA met with Executive Director Kippie Castronovo and explained the purpose of today's visit. Regarding the allegation of staff engaged in a verbal altercation in the presence of residents, Reporting party (RP) stated that during the incident, a staff (S1) was with another staff (S6) and had entered in the apartment when handing the medication to the RP for discharge. RP placed his/her hand on the door of the apartment and asked S1 if they can discuss this. S6 said RP was not listening to S1. RP states to have placed his/her hand on the door which can prohibit staff from exiting the room, so they can talk about the situation. RP states S1 opened the door and started screaming at her more in the hallway. A resident (R1) was a witness and RP states R1’s jaw dropped. page 1 of 2 Unsubstantiated LPA Dolores interviewed five residents one of which is R1. R1 stated that he/she has never observed or heard of a verbal altercation with staff and a resident/family member at the facility. R1 also states to have never observed or heard of a verbal argument that occurred at the facility with staff and a resident/family member. R1 states to be perfectly happy and has no concerns with the staff. LPA Dolores also interviewed staff, one of which is S1. S1 stated to not consider these interactions as an altercation, but as a conversation they had. S1 added that on 07/11/2022, RP was requesting for all of R2s medications. There was a misunderstanding with the medications. On 07/12/2022, S1 brought the bottles of medications to R2s room. Another staff member (S2) added that there was no altercation. Med tech's were pressured by RP to sign off meds. Then reported that they demanded the meds. When RP was in possession of the meds there was no provided care. S2 clarified that they will provide the care. The conversation happened in the room not in the hallway. No one was raising their voice. Additionally, other residents interviewed R5, R6 & R7 mentioned that they were not aware of any incidents or altercation regarding a family member and a staff. Also staff members S3, S4 & S5 added that they have not witnessed, observed, or heard of a verbal altercation/argument with a staff member and resident/family member at the facility while on duty. There weren’t also any concerns brought to them by any staff or resident. Based on interviews & records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. page 2 of 2the state’s words, verbatim · CDSS document, Aug 26, 2024 · control 26-AS-20220712170531

Allegation investigated: Staff did not maintain accurate resident records Staff disclosed resident confidential records with unauthorized person

On 8/26/2024, Licensing Program Analysts (LPAs) Grace Donato & Christine Dolores conducted an unannounced complaint investigation visit. LPA met with Executive Director Kippie Castronovo and explained the purpose of today's visit. Regarding the allegation of staff did not maintain accurate resident records, Reporting Party (RP) stated that facility failed to keep a complete and current record for resident (R1). Per the RP, the listed Primary Physician PCP and Pharmacy were in error, Facility has not updated "Diagnoses" on records to include R1s diagnosis of Acute Low Salt Syndrome. page 1 of 2 Substantiated Based on records review, LPA Donato was able to obtain three physicians reports (LIC602). The reports from 1/11/2019 and 10/26/2020 were from the first primary physician (PCP1) of R1. On the face sheet provided by the facility to the RP, with the print date of 11/29/2021, the physicians (PCP2) name did not match the LIC602. PCP2 has never met R1, nor signed any LIC602 for R1. The diagnosis of Acute Low Salt Syndrome was never mentioned in any LIC602. The name of the pharmacy has been updated to the current one during that time. Regarding the allegation of staff disclosed resident confidential records with unauthorized person, RP stated that facility breached Confidentiality and Privacy of Records by forwarding, to RP, Residents (R2), covid-19 test results, dated 02/03/2022, without permission or authorization. LPA Dolores interviewed two staff members. S1 stated that there was an incident where staff(S3) mistakenly shared R2s test with another family member. S3 admitted to sending the test to RP unintentionally. Based on records review, LPA Dolores received copy of the said report from RP. Therefore, based on interviews and records review and information collected, the above allegations are determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. A copy of this report and the Appeal Rights are provided. page 2 of 2the state’s words, verbatim · CDSS document, Aug 26, 2024 · control 26-AS-20220517124344

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(9) · Plan of correction due date: Aug 21, 2024

87506 Resident Records (b) Each resident’s record shall contain at least the following information: (9) Name, address and telephone number of physician and dentist to be called in an emergency. This was not met as evidenced by: Based on records review, R1s PCP is not the correct physician in the face sheet, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 26, 2024

Plan of correction: Licensee to submit an audit report of records. Licensee to submit on POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c) · Plan of correction due date: Aug 21, 2024

87506 Resident Records (c) All information and records obtained from or regarding residents shall be confidential. This was not met as evidenced by: Based on record reviews, RP was able to receive a covid report of another resident which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 26, 2024

Plan of correction: Licensee to do in-service training regarding confidentiality of records. Licensee to submit proof of training by POC due date.

Allegation investigated: Facility did not adhere to the residents admission agreement

On 8/26/2024, Licensing Program Analysts (LPAs) Grace Donato & Christine Dolores conducted an unannounced complaint investigation visit. LPA met with Executive Director Kippie Castronovo and explained the purpose of today's visit. Regarding the allegation of facility did not adhere to the residents admission agreement, Reporting Party (RP) stated that facility proposed a certain fee and once they paid for all the moving they gave a revised assessment that increased the fees. Based on records review, the resident (R1s) moved in the facility on 1/24/2019, based on the admission agreement. On 1/28/2019, R1 was given an intitial assessment and was charged a new rate. The assessment rate has changed and is different from what was agreed upon move in. The fee for care services is at $3,179, however on the assessment on 1/28/2019 it changed to $4,148, which had become effective on 2/1/2019. Therefore, based on interviews and records review and information collected, the above allegation is determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. A copy of this report and the Appeal Rights are provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 26, 2024 · control 26-AS-20220923105257

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(3)(B) · Plan of correction due date: Sep 3, 2024

87507 Admission Agreements (g)Admission agreements shall specify the following: (3) Payment provisions, including the following:(B) Rate for additional items and services, including: 1. A comprehensive description of and the corresponding fee schedule for all additional items and services not included in the fees for basic services shall be listed. This was not met as evidenced by: Facility did an intitial assessment after R1s move in which changed the agreed upon rate in the admission agreement.the state’s words, verbatim · CDSS document, Aug 26, 2024

Plan of correction: Licensee to submit a plan to address how assessments shoud be done before finalizing an admission agreement. Licensee to submit in-training log by POC due date..

Allegation investigated: Resident sustained an unexplained bruise while in care Staff handled resident in a rough manner Staff spoke and yelled at resident in an inappropriate manner Staff is unable to meet residents needs with a sprained arm

Licensing Program Analysts (LPAs) Christine Dolores and Grace Donato arrived unannounced to deliver the finding regarding the above allegations. LPA met with Executive Director, Kippie Castronovo. On 12/05/2023, the Department received the complaint regarding the above allegations. On 12/14/2023, the initial complaint investigation was conducted. The following documents were obtained to include resident (R1)'s physician's report, appraisal/needs and services plan, medication administration record, progress notes, third party communication forms, resident roster, staff roster, staff schedule from November - December 2023, staff members contact information, S1’s physician's note regarding injury, email correspondences, incident report, and police reports. PAGE 1 OF 5. Unsubstantiated It was alleged that on 11/28/2023, R1’s responsible party found a bruise on R1’s arm and the staff was unable to explain how it happened. The review of the photograph shows a purple and reddish discoloration measuring approximately 3-4 inched (linear) on the right forearm. On 11/28/2023, R1’s responsible party notified the facility staff via email regarding the observation of a long bruise on R1’s arm. Based on the email, R1 denied any pain and did not recall how it happened. It was stated they were thinking it could have happened at the exiting doorways or when R1 moved in and out of the dining table. R1’s responsible party advised staff to be extra careful when maneuvering R1 in the wheelchair since R1 is on a certain medication. On 11/29/2023, the facility staff (S3) replied stating that S3 was with R1 and did not notice any bruising on R1’s arm. It was stated that the care staff put lotion on R1 and did not notice the bruising the last two days either. It was stated that S3 checked in on R1 that morning and seemed to be okay with no complaints of pain. S3 states to believe the bruise was from the wheelchair because R1 rests and puts pressure on the arm rest. 10 staff members were interviewed. S6 states to have seen the bruise but was unsure on how R1 sustained the bruise. S6 states to not have noticed the bruise because R1 was wearing a long sleeve that day and that he/she only changes R1 into pajamas when R1’s responsible party arrives. S6 noticed the bruise when changing R1’s clothes and reported the observation to the Medtech. Staff (S4) (S5) and (S7) believed that the bruise was from R1’s wheelchair. S4 and S5 states R1’s sleeps on the wheelchair and would lean on the arm rest. Based on record review, the facility’s noted their observations of R1 per each shift from 11/25/23 – 12/2/2023. There was no note regarding the observation of any bruising on R1’s skin prior nor incidents that may have caused the bruising prior to 11/28/2023. R1 was also receiving services from a third party and based on the records, the resident was unable to recall what happened. It was noted that the bruise was possibly from the old wheelchair. PAGE 2 OF 5. It was alleged that R1 reported to his/her responsible party on 11/25/2023 that a staff yelled and “was really rude and mean and rough” with R1 during the night shift. It was also alleged that on 12/02/2023, R1 reported to his/her responsible party that a staff was rough with him/her during the night shift and pushed R1’s shoulder while changing him/her and spoke aggressively to R1. 11 staff members were interviewed regarding the allegation of rough handling a resident. 11 out of 11 staff members denied any staff handling residents in a rough manner. 11 out of 11 staff members denied the observation of another staff handling R1 in a rough manner. 11 staff members were interviewed regarding the allegation of staff speaking and yelling at a resident in an inappropriate manner. 11 out of 11 staff members denied speaking inappropriately to residents. 11 out of 11 staff members denied the observation of staff speaking inappropriately to residents. On 12/14/2023, 2 residents were interviewed. LPA Dolores was unable to properly interview R1 due to behaviors the resident began to experience during the interview. R2 stated the staff are for the most part gentle when caring for R2. R2 denied staff yelling at him/her or other residents. The review of the facility’s records shows that the facility was notified on 12/01/2023 by R1’s responsible party that a NOC staff (S1) was being rough and talking in an angry voice. This was reported by R1 to R1’s responsible party. There is no record showing the facility was notified of the alleged incident on 11/25/2023. Based on record review, from 11/25/23 – 12/2/23 R1 was observed during the NOC shift. On 12/1/23, it was noted that R1 slept through the whole night but didn’t want to change and hit the care staff. R1’s care was then endorsed to the morning care staff. Record shows that on 12/02/2023, the facility staff conducted an internal investigation. Based on the records, the resident stated all staff treats R1 very well and R1 is not being treated badly or rough. PAGE 3 OF 5. On 12/05/2023, the police were called to the facility. Based on review the report, R1 stated that a suspect had hit him/her in the head with his/her hand and a diaper while changing R1. R1 attempted to defend him/herself and the suspect held R1 down causing R1 to sustain a bruise on his/her arm. R1 described the physical appearance of the suspect. A staff verified the suspect’s name, but the last name was handwritten and illegible based on the list that was provided. It was indicated that the suspect was unidentified and still at large. The review of the staffing schedule shows that 2 NOC staff was scheduled during the night of 12/01/23 and 12/02/23, to include S1. Based on interview with S1, S1 states to not have done anything to wrong to R1. S8 stated to have witnessed one night when R1 refused to be changed and smacked S1’s hand. S8 stated that R1 was agitated so they both agreed to try again later. S8 denied S1 being rough and speaking inappropriately to R1. The review of R1’s records shows that R1 is diagnosed with a major neurocognitive disorder. Staff is unable to meet residents needs with a sprained arm It was alleged that on 11/26/2023 staff (S2) was working with a sprained arm and was unable to assist R1 when requested by R1’s responsible party. It was alleged that R1’s legs were misaligned in the wheelchair and R1 was crying for help and S2 did not attempt to get help. Based on record review, S2 had a physician’s note which included modified activity and restrictions. 9 staff members were interviewed regarding this allegation. Based on interview, it was stated that S2 did have a sprained arm, however, was not assigned as a caregiver. S2 was assigned to complete computer work instead. PAGE 4 OF 5. Based on interview with staff (S2), it was stated that due to S2’s limitations, S2 was not caregiver and was only assigned to computer work. S2 stated to be in the common area because another staff needed to do something. S2 was supervising the residents for a moment while the caregiver stepped away and while S2 was in the common area, R1’s family member asked for help in which S2 apologized as S2 was unable to assist due an injury. It was stated that shortly after, S2 followed-up with a caregiver to inform the caregiver of the situation, in which that caregiver was able to assist R1. Based on the facility’s memory care staffing schedule for November 2023, there was at least 3 – 4 caregivers scheduled in the PM and 2 staff during NOC. S2 was not part of the list of caregivers scheduled during the date this incident was alleged on 11/26/2023. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove a violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Kippie Castronovo and a copy of the report was provided. PAGE 5 OF 5.the state’s words, verbatim · CDSS document, Aug 26, 2024 · control 26-AS-20231205162429

Allegation investigated: Staff do not respond timely to the residents alerts

Licensing Program Analysts (LPAs) Christine Dolores and Grace Donato arrived unannounced to deliver the findings for the above allegation. LPA met with Executive Director, Kippie Castronovo. On 12/11/2023, the Department received the complaint. On 12/14/2023, the initial complaint investigation was conducted. The following documents were obtained to include the call alert records in assisted living and memory care from November – December 2023 and staff schedule. PAGE 1 OF 2. Substantiated It was alleged that residents in assisted living shared that staff are not responding to their alert calls when they press their pendant. It was alleged that staff respond that they are understaffed. It was also alleged that on 12/10/2023, a resident’s (R5) responsible party pressed the pendant and alert button and did not receive a response. Based on record review, in November 2023 there were 801 calls with a response time of 10 minutes and more. From 12/01/2023 – 12/13/2023 there were 383 calls with a response time of 10 minutes and more. Based on record review of the call button log on 12/10/2023 from R5, there was 4 calls with a response time of 10 minutes and more. 10 residents were interviewed. 4 out of 10 residents state that sometimes it takes the staff a long time to respond to their pendant alerts. R1 states that sometimes it takes staff up to 40 minutes to respond. R1 states that it takes the longest in the middle of the day and sometimes in the morning between 7:00am – 8:00am. R2 states the response can take up to 30 minutes. R2 states the response time is slow in the middle of the day. R3 states it takes a “long time” for staff to respond if they are busy, especially at dinner time. R4 states the average wait time is about 30 minutes. 4 out of 4 residents states the facility is understaffed which is the reason they cannot respond timely. Based on staff interview, it was stated that staff should respond to pendant alerts within 10 minutes. The Department has investigated the above allegation. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency was cited today per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Kippie Castronovo and a copy of the report and appeal rights were provided. See LIC9099-D. 7 staff were interviewed. Based on staff interview, 7 out of 7 staff state the residents food comes out warm. 7 out of 7 staff state they have a microwave in memory care and will re-heat the resident’s food if they complain it is cold. 10 residents were interviewed. 10 out of 10 residents state the food comes out warm. 7 out of 10 resident states that staff can warm up their food in the microwave if needed. On 12/14/2023, LPA Dolores observed the memory care dining room area during lunch time. The food warmer temperature was maintained at 115 degrees Fahrenheit which stored all the residents lunch. The surface of the plate and bowls were observed warm. LPA Dolores observed a microwave in the dining room area. Staff stated they use the microwave in the resident’s complaint that their food is cold. It was alleged that NOC shift staff are sleeping leaving no staff on the floor to provide care and supervision to the residents. 10 residents were interviewed. 10 out of 10 residents are not aware of any NOC shift staff sleeping during the night. 10 out of 10 residents denied being left unattended where there were no staff to respond. 7 staff members were interviewed. 7 out of 7 staff are not aware of any staff sleeping during their shift. 7 out of 7 staff denied leaving the residents unsupervised. Based on record review, the facility schedules at least 2 NOC shift care staff in assisted living and memory care daily. It was alleged that the facility does not provide a comfortable living environment for the residents in memory care because of the family room TV is extremely loud. 5 residents in memory care were interviewed. R5 and R7 states to ask staff to turn down the volume if they TV volume is too loud. R5 and R7 states the staff will turn down the volume. R6 does not think the TV is too loud. PAGE 2 OF 3. 7 staff were interviewed. 7 out of 7 staff state the volume of the TV in memory care is not too loud. S1 and S6 states they have residents who complain when it’s loud and they’ll put it down, like R7. S1 states the residents are verbal about the TV being too loud. S3 states that sometimes the volume gets too loud during commercials, and they’ll lower or change it. S5 states to have come to the facility unannounced during the PM time and did not observe the TV was loud. S6 denied the TV being too loud where they can’t hear. On 12/14/2023, LPA Dolores observed the dining room and activities area in memory care. LPA observed the TV was on and the volume was loud but none of the residents were complaining. LPA observed that although the TV was loud, LPA was able to hear surrounding noise to include staff to resident conversations. It was alleged that staff are not properly trained on medication because the MedTech’s do not have knowledge on medications and their side effects. Based on record review, MedTechs are provided with 24 hours of initial medication training to include hands-on shadowing training and topics on medication management, medication orders and/ working with pharmacies, medications and documentation's, assistance with medication administration, side effects, adverse reactions, and medication errors, and understanding California medication regulations. 3 MedTech’s in memory care were provided at least 24 hours of initial training on medication. Based on recover review, staff were provided in-service training on medications on 12/01/2022, 01/18/2023, 05/11/2023, 05/23/2023, and 11/02/2023. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegations may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Kippie Castronovo and a copy of the report was provided. PAGE 3 OF 3. It was alleged that a staff (S8) is performing duties without an appropriate skilled professional present. It was alleged that the health service director was administering residents flu shots in October 2023. Based on staff interview, S8 states they contract with a third-party vendor to administer the flu shots. S8 denied administering any flu shots to residents in October 2023. S8 states he/she was only helping with the paperwork but denied injecting any flu shots. The Executive Director stated that S8 does have an LVN license but does not perform any LVN duties. S8 job duties includes care plan assessments and change of condition assessment. The ED stated that the facility is not a medical facility and are not required to have any doctor’s or registered nurses. The Department has investigated the above allegation. Based on interviews, record review and observation the above allegations is unfounded meaning the allegations is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Kippie Castronovo and a copy of the report was provided. PAGE 2 OF 2.the state’s words, verbatim · CDSS document, Aug 26, 2024 · control 26-AS-20231211103328

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Aug 26, 2024

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care... This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not ensure the staff were sufficient in numbers to respond timely to the resident’s call buttons which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 26, 2024

Plan of correction: Licensee states they are currently fully staffed. Licensee will submit the staffing schedule for AL and MC to LPA Dolores via email by POC due date.

Allegation investigated: Resident was unlawfully evicted while in care

On 7/18/24, Licensing Program Analysts (LPAs) Grace Donato, Christine Dolores & Kiran Jain conducted an unannounced complaint investigation visit. LPA met with Executive Director Kippie Castronovo and explained the purpose of today's visit. Regarding the allegation of resident was unlawfully evicted while in care, reporting party (RP) stated that an unlawful 30-Day Notice of Termination of Residence Agreement was served on May 13, 2022. Based on interviews, LPA Dolores spoke with Health Service Director (HSD) regarding the Eviction on June 6, 2022. LPA informed HSD to resubmit this Eviction Letter to include more details of dates/times of specific events leading to the eviction. LPA informed HSD that once the eviction letter is re-written the 30 days would start over. page 1 of 2 Substantiated On June 12, 2022, AED emailed LPA a revised eviction letter dated June 13, 2022 to include all information requested. On July 12, 2022, LPA spoke with AED to inform that the Eviction Notice dated July 13, 2022 is invalid due to the reasons listed below: - The 30th day is incorrect. - The eviction notice does not include the address of the State Local Long Term Care Ombudsman - Does not list out information on resources in identifying alternative housing and care options, including public and private referral services and case management organizations. While the letter that was sent on June 12, 2022 was previously approved, it was reviewed again by another Licensing Program Manager (LPM) at this time and it was deemed unlawful due to the reasons mentioned. Therefore, based on interviews and records review and information collected, the above allegation is determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. A copy of this report and the Appeal Rights are provided. page 2 of 2the state’s words, verbatim · CDSS document, Jul 18, 2024 · control 26-AS-20220602091807

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(d)(1) · Plan of correction due date: Jul 18, 2024

87224 Eviction Procedures (d)The licensee shall set forth in the notice to quit the reasons relied upon for the eviction...(1)The notice to quit shall include the following information: This requirement was not met as evidenced by: Based on interviews & records review the facility gave the R1s responsible party an unlawful/invalid letter of eviction which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 18, 2024

Plan of correction: Facility has already corrected the letter and provided it to the responsible party.

Allegation investigated: Staff do not attend to resident in care in a timely manner Staff did not report resident’s incident to resident’s representative Facility is not treating a resident’s visitor with dignity Facility financially retaliated against resident

Licensing Program Analyst (LPA) Christine Dolores, Grace Donato, and Kiran Jain arrived unannounced to deliver the finding for the above allegations. LPA met with Executive Director Kippie Castronovo. On 11/06/2023, the Department received the complaint regarding the above allegations. On 11/16/2023, the initial complaint investigation was conducted. The following documents were obtained for this investigation to include the staff schedule from October 21, 2023 to October 26, 2023, call button report from November 1, 2023 to November 30, 2023, resident (R1)’s admission agreement, physician’s report, cares assessments, charting notes for November 2023, third party communication notes, special care instructions, and other correspondences. PAGE 1 OF 5 Unsubstantiated Staff do not attend to resident in care in a timely manner On 11/06/2023, it was alleged that the facility staff do not attend to resident (R1) in a timely manner when R1 calls out for help and that no one comes to R1 “for a very long time”. The concern was that staff are unable to hear R1 crying for help as R1’s room was located in the back corner. During the course of this investigation, 10 staff members were interviewed. Based on interview, 10 out of 10 staff state that staff attend to R1 when R1 they hear R1 calling for assistance. It was stated that if staff are busy assisting other residents, then it’s difficult for staff to get to R1 right away. It was stated that the facility frequently checks in with the residents, but they do not have a specific timeframe for how frequently staff are required to check in with the residents. 9 out of 10 staff stated they check in with the residents every 1-2 hours. 1 out of 10 staff stated they conduct “frequent checks” but was unable to elaborate more on the timeframe. It was stated that residents who require more care needs are checked on more often. Based on staff interviews, it was stated that due to R1’s needs, the facility recommended a 1:1 caregiver for R1 during the night however due to financial reasons, R1 was unable to be provided a 1:1 caregiver. Due to R1’s behaviors during the night, the facility temporarily implemented a NOC shift staff to sit with R1 during the night. It was stated that the staff tried to their best to accommodate to R1’s needs. It was stated that due R1’s behaviors during the night, the facility provided R1 a pendant on 11/08/2024. Staff did not report resident’s incident to resident’s representative On 11/06/2023, It was alleged that the facility staff did not report a resident’s fall incident on the night of 10/21/2023 to the R1’s representative/responsible party. The fall incident was verbally reported by R1 to R1’s responsible party and a home health agency nurse. It was reported to R1’s responsible party that R1 fell while being assisted by staff to bed on 10/21/2024. R1’s responsible party informed the facility staff regarding the fall. PAGE 2 OF 5 Based on record review, there were no notes in R1’s file regarding a fall on 10/21/2023. On 10/22/2023, it was noted that R1’s responsible party claimed the bruise on R1’s buttocks was a result of a fall from the night of 10/21/2023. Staff informed R1’s responsible party that there were no reports regarding any falls. 5 staff members were interviewed regarding the allegation. Based on interview, 5 out of 5 staff denied the observation and knowledge of R1’s witnessed fall on the night of 10/21/2023. It was stated that R1 reported the fall to R1’s responsible party, who then reported the fall to the facility staff. When staff was made aware of the fall, R1’s responsible party did not allow staff to ask R1 additional questions regarding the fall. The facility conducted their internal investigation and staff did not report any witnessed falls or incidents with R1 that night of 10/21/2023. It was stated that because there was no report regarding R1’s fall, the facility treated the incident like it never happened. 2 staff stated the observation of a bruise on R1’s buttocks but did not know where the bruise came from. Staff endorsed the observation and continued to monitor R1’s bruise. 1 witness (W1) was interviewed. Based on interview, W1 denied the observation or knowledge of a witness fall. W1 denied the observation of seeing a bruise on R1’s buttocks that resulted from a fall. Facility is not treating a resident’s visitor with dignity On 11/06/2023, the reporting party (RP) alleged that the facility staff is not treating a resident (R1)’s visitor with dignity. It was alleged that the facility was told by management to monitor R1’s responsible party’s visitation by informing the facility’s management when R1’s visitor arrives and departs from the facility. Based on staff interview, all visitors in the community are required to abide to the same visitation policy and procedures. All visitors are required to sign in at the front desk and the front desk monitors the time the visitor departs from the facility. If visitors are in the community after 8:00PM, the staff should be aware of the visitation for safety reasons. PAGE 3 OF 5 9 staff members were interviewed regarding the allegation. Based on interview, 9 out of 9 staff denied monitoring any resident’s visitors in the community to include memory care. 9 out of 9 staff members denied monitoring R1’s visitor when in the community. 9 out of 9 staff members denied the requirement to inform management when R1’s visitor arrived or departed from the facility. During staff interviews, it was stated that after 8:00PM the concierge leaves and staff walk the visitors out because the doors are locked. One night, staff needed to walk R1’s visitor out and R1’s visitor randomly commented telling the staff to text his/her boss that R1’s visitor is leaving. Staff stated to not know why R1’s visitor commented that and ignored the comment. Staff denied having to inform the facility’s management when R1’s visitor arrived or departed from the facility. Facility financially retaliated against resident On 11/06/2023, it was alleged that the facility financially retaliated against R1 by increasing R1’s care fees. 1 witness (W1) was interviewed. Based on interview, the facility raised the resident’s rate because of R1’s 2 falls. It was stated that the facility was “nit-picking” R1’s DPOA and it seemed to be retaliating. It was stated that there was no concern with the care and quality of care the facility provides R1, and everything seemed to be towards R1’s DPOA. Based on record review, R1 had an initial assessment dated 10/13/2023 (move-in date). On 11/02/2023, the care assessment was drafted to include the increase of care. R1’s assessment on 10/13/2023 and 11/02/2023 was compared and the assessment on 11/02/2023 shows the increase of care to include grooming, toileting, fall management, time/place orientation, and behaviors to include restless, verbally disruptive, delusions and hallucinations, and combative. PAGE 4 OF 5 Based on staff interview, it was stated that after 2 weeks of the resident’s admission they check and reassess the resident to ensure they have the right care plan. On 11/02/2023, a draft of the increased care assessment was provided to the reporting party but the care increase was not carried out and was only a draft. It was stated that the care increase did not start as they haven’t had another care meeting to discuss the increase of care. It was stated the increase of care was because R1 actually required more care based on their observations after R1 moved into the facility. 10 staff members were interviewed regarding the allegation. Based on interview, R1 required total care and full assistance with activities of daily living (ADLs) to include mobility, transferring, toileting, showering, and grooming. The review of R1’s records show that from 10/14/2024 – 11/02/2024, facility observed and noted their observations of R1 to include grooming (showers), toileting, 1 fall, and behaviors to include yelling and crying for staff, delusions and hallucinations, and combativeness with staff. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the allegations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Kippie Castronovo and a copy of the report was provided. PAGE 5 OF 5the state’s words, verbatim · CDSS document, Jul 18, 2024 · control 26-AS-20231106161659

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Christine Dolores and Grace Donato arrived unannounced to conduct a case management – incident visit. LPA met with Business Office Director, Francisco Sudiacal. This case management visit is a follow-up from the initial visit conducted on 01/17/2024. On 01/17/2024, the Department was informed that resident (R1) immediately vacated and removed all his/her personal belongings from the facility on 12/28/2023. It was alleged that the facility did not issue R1 a refund within 15 days. It was also alleged that the facility did not issue the full refund based on the Final Account Statement that was provided to R1’s designated power of attorney (DPOA) upon move-out. The review of records shows that on 12/29/2023, the facility’s corporate office personnel emailed R1’s responsible party stating that a refund check will be received via mail within 15 days, however R1’s responsible party received the refund after 15 days. Based on review of R1’s signed admission agreement, it is stated on page 9 #4(b) “within 30 days after your apartment has been vacated and property has been removed from it, Oakmont shall pay you and your representative a refund of any prorated unused portion of your final Monthly Fee payment, a prorated amount of the Community Fee …” On 01/17/2024, the Executive Director was interviewed. Based on interview, R1 was exempt from the requirement to submit a 30-day written notice of termination per the admission agreement (page 7-8) to receive a refund. R1 was not exempt from receiving a refund within 30 days. SEE LIC809-C. On 01/24/2024, a representative of R1 acknowledged the receipt of the refund. In the letter, the facility was questioned on the final account statement “variance – account balance – refund due” line. The review of R1’s final account statement listed a “variance – account balance – refund due” line with a set amount. Based on interview, staff originally calculated R1’s “variance – account balance – refund due” based off of the original community fee rate agreed upon during admission. During the course of the interview, it was disclosed that R1 was given a discount of the community fee rate. It was stated that upon review of the final account statement it was found that the facility had used the original community fee rate, instead of the discounted actual community fee payments received. Once the error was found, staff manually edited and recomputed R1’s refund based off of the actual community fee payments received. Since R1 was discharged during the third month of residency, R1 was required to receive a refund of at least 40% of the preadmission fee (community fee) per Title 22 Section 87507(g)(5)(E)(2)(c). R1’s actual refund amount was 40% of the three community fee installments paid on 10/01/2023, 11/15/2024, and 12/01/2023. R1 was also refunded a care credit. Based on review of R1’s account ledger, the actual refund R1 received shows to be correct. During visit, a complaint for control number 26-AS-20240124171324 was amended. No deficiencies were cited today per California Code of Regulations, Title 22. This report was reviewed with Business Office Director, Francisco Sudiacal and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 8, 2024

Allegation investigated: Resident sustained a pressure injury due to staff neglect Staff did not administer resident's medication Staff left resident in soiled diapers for an extended period of time Staff are not meeting residents needs Facility does not have adequate staff is memory care to meet the residents needs

On 5/10/24, Licensing Program Analysts (LPAs) Grace Donato & Christine Dolores conducted an unannounced complaint investigation visit. LPAs met with Interim Executive Director, Christopher Schuster and LPA explained the purpose of today's visit. Regarding the allegation of resident sustained a pressure injury due to staff neglect, Reporting Party (RP) stated that stated that resident (R1) has a pressure sore on the butt (doesn’t know how big) and the home health nurse comes three times per week to clean the wound. RP stated that R1 has never had pressure sores before. RP stated that the staff are just leaving R1 in the wheelchair all day which is causing the sores. On 12/16/23, RP noticed a blister on the heel of R1, it was then reported to the Physician and RP made the staff aware of it. ...PAGE 1 of 4 Substantiated LPA Dolores interviewed a staff member (S1) and it was mentioned that when they we redoing the assessment for R1, RP didn’t allow the staff to check R1s skin. RP told there’s no pressure injury and R1 has redness on the bottom but it’s okay. Upon moving in, the Health Services Director (HSD) wasn’t here. They weren't able to do the skin check upon move in day. It was reported later that there was a tiny opening of .5 cm. HSD checked it and reported it to RP, doctor, and requested home health when they found out there was an opening. There is a PRN cream that needs to be applied. Normal procedure is to do a skin check prior to move in but RP was saying no need to because R1 doesn’t have any issues. That’s the only one that they didn’t do the skin check for. Another staff member, S5, mentioned that R1 has some type of pressure injury and it was not staged. During the pre-assessment there was redness but didn’t check R1s skin. Family didn’t let them check the skin. LPA Donato was able to interview the Home Health Nurse and it was confirmed that the pressure injury was at stage two. Based on records review, a charting report showed that on 12/16/2023 input by S6 at 9:30PM that R1 had a blister on left heel and Tylenol was given for pain and discomfort. Regarding the allegation of staff did not administer resident's medication, RP stated that R1 has butt paste to prevent R1 from getting pressure sores and the staff haven’t been putting it on. LPA Donato reviewed the Medication Administration Records (MAR) of R1, and it shows that the cream that was prescribed as needed (PRN) and had a direction of being applied topically each bowel movement/diaper change was not done regularly. MAR from October 19-31 2023 showed the cream was only applied for seven random days. MAR from November 2023 also showed cream being applied three to four random days. ...PAGE 2 of 4 LPA Donato did a records review and facility was able to provide documentation for in service training regarding Resident Fall Management, Proper Positioning, Bowel Protocol and annual trainings for Dementia Care-Performing ADLs (Activities of Daily Living) and Assisting with ADLs. Based on interviews and records review, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. Report is reviewed and copy is provided. ...PAGE 2 of 2 Regarding the allegations of staff left resident in soiled diapers for an extended period of time and Staff are not meeting resident’s needs, RP stated that R1 is not being changed enough and ends up with soaked diapers and clothing. RP stated that the staff have even put double diapers on R1 to get out of changing her. Based on records review, a photo evidence was submitted by RP showing a soiled double diaper that was removed from the resident. On R1s individualized service plan dated 10/16/23, it is noted that R1 takes a medication which makes R1 urinate a large amount up to six hours after the first dose so R1 needs to go frequently to toilet. An document was obtained acknowledging that RP addressed the double diapers to the facility and that facility acknowledged this and stated that it will address the situation. LPA Dolores interviewed five staff members. S2 mentioned that he/she doesn’t know of any soiled diapers. S3 stated that R1 is not left for a long time and changes R1s diaper as soon as needed. Regarding the allegation of facility does not have adequate staff in memory care to meet the resident’s needs, RP stated that there is not enough staff to handle the residents in memory care. Based on records review, the month of October 2023 there are three to four caregivers scheduled per shift and this does not include the med tech. Shift times start at 6am to 2pm, 2pm to 10pm and NOC shift, 10pm to 6am has 2 staff scheduled. During the interview, S2 mentioned that they are not short staffed in memory care. S2 has seven residents under his/her care. S3 stated that they normally have the same groups of residents and currently has six in the group. S4 stated that there are usually three caregivers. On Wednesday and Thursdays there are four. S4 is the extra and they have enough staff to care for the residents. S4 also mentioned that there are three caregivers on the floor and med tech steps in. Ratio is one caregiver is to six or seven residents. Time management is very important, so they can meet their needs. ...PAGE 3 of 4 However, S3 also mentioned that R1 needs a diaper change about four to five times during the shift. R1 also is not able to go to the bathroom unassisted. S5 also mentioned that R1s toileting happens every two hours. R1 has diaper changes around four to five times and during night shift will be two to three times. Based on interviews, records review and information collected, the above allegations are determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. A deficiency was cited during today’s visit, see LIC809-D. A civil penalty for repeat violation within the 12-month period is being assessed for the amount of $250, see LIC421FC. Additional civil penalties are pending review. A copy of this report and the Appeal Rights are provided. ...PAGE 4 of 4the state’s words, verbatim · CDSS document, May 10, 2024 · control 26-AS-20231027084308

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87457(a)(2) · Plan of correction due date: May 11, 2024

87457 Pre-Admission Appraisal – General (a)Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions. (2) The prospective resident's desires regarding admission, and his/her background, including any specific service needs, medical background and functional limitations shall be discussed. This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above due to staff wasn't able to conduct skin check to determine if there is pressure injury on R1 prior to admission which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 10, 2024

Plan of correction: Licensee to submit a plan on how to address Pre-Admission Appraisals for future residents. Licensee to submit by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: May 11, 2024

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly (2)Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on interview and records review, the instructions of the PRN medication prescribed by the physician was not followed. Medication was only applied on random days, not every change in diaper or bowel movement which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 10, 2024

Plan of correction: Licensee to submit a plan and in-service training regarding medication administration. Licensee to submit by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: May 11, 2024

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning... When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented... This requirement is not met as evidenced by: Based on interview and records review, RP noticed the blister and then made the facility and physician aware, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 10, 2024

Plan of correction: Licensee to submit a plan and in-service training Observation of Resident. Licensee to submit by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a)(3) · Plan of correction due date: May 11, 2024

87463 Reappraisals (a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate...Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition... This requirement is not met as evidenced by: Based on interview and records review, facility did not do a reappraisal based on the need of R1 for toileting due to a medication that causes her to urinate a large amount which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 10, 2024

Plan of correction: Licensee to submit a plan to address Reappraisals of resident. Licensee to submit by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 11, 2024

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care... This requirement is not met as evidenced by: Based on interviews, R1 needed more assistance with incontinence and there was not enough staff to be able to cater for the needs of R1 which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 10, 2024

Plan of correction: Licensee to submit a plan and in-service training regarding medication administration. Licensee to submit by POC due date.

Allegation investigated: Facility failed to seek timely medical attention which resulted in resident hospitalization

Licensing Program Analysts (LPAs) Christine Dolores and Grace Donato arrived unannounced to deliver the complaint investigating finding regarding the above allegations. LPA met with Interim Executive Director, Christopher Schuster. On 12/27/2023, the Department received a complaint alleging facility staff failed to seek timely medication attention which resulted in resident hospitalization. On 01/05/2024, the initial complaint investigation was conducted. The following documents were obtained to include resident (R1 – R5’s) records: physician’s report, individualized service plan, resident assessment, charting notes, medication administration record (MAR), resident roster, traditions shower schedule, and medical records. PAGE 1 OF 3. Substantiated On 12/26/2023, resident (R1) began to develop flu-like symptoms. R1’s responsible party was made aware. The review of records shows that on 12/26/2023 around 11:00PM, R1’s responsible party contacted the facility to follow-up on R1’s condition. R1’s responsible party instructed the facility staff to monitor R1’s condition as R1 was not feeling well. It was noted during NOC shift that R1 had on and off coughing and was not feeling well but slept through the night. On 12/27/2023, between 6:30AM – 7:00AM, staff observed resident was sleeping. Around 8:00AM, staff checked R1. At 9:00AM, staff contacted R1’s responsible party regarding R1’s condition. R1 was observed to be wheezing, had a runny nose, and coughing. R1’s responsible party was stated to be on the way to the facility within an hour. Record review shows that after the telephone call to R1’s responsible party staff offered R1 breakfast, which R1 initially refused. Staff (S8) offered R1 yogurt and water, which R1 partially consumed prior to taking his/her medications. R1 was observed to be responsive but weak. Around 10:00AM, R1’s responsible party arrived to the facility and observed R1 laying in bed, unresponsive, and pale in color. R1’s responsible party contacted emergency services and R1 was then transported to the hospital. 8 staff members were interviewed. 5 out of 8 staff interviewed were familiar with R1’s care. 1 out of 5 staff members stated the observation of R1 looking weak the night before he/she went to the hospital (12/26/2023). 5 out of 5 staff stated the observation of R1 feeling unwell the morning of 12/27/2023. Based on interview, staff did not offer to contact emergency medical services when the initial telephone call was made to the RP. Staff stated they did not offer to contact medical services because RP stated to be on the way. The review of medical records shows that upon arrival of emergency medical services, R1 had an altered level of consciousness, shortness of breath, and a fever. R1 was hospitalized and diagnosed with a life-threatening infection and virus. PAGE 2 OF 3. On 12/26/2023, resident (R1) began to develop flu-like symptoms. Around 6:00PM, R1’s responsible party spoke with R1 who only speaks another language but English. R1 told his/her responsible party that his/her head was hurting all day and was not feeling well. The responsible party contacted staff and requested to dispense a PRN medication for R1. R1’s responsible party arrived to the facility about 45 minutes after the telephone call, and was informed by R1 that he/she has not yet received their PRN medication. Based on record review, the physician’s order for R1’s PRN medication states an instruction for “as needed”. R1’s PRN medication was dispensed around 8:00PM on 12/26/2023. Throughout the investigation, 3 witnesses were interviewed. 3 out of 3 witnesses denied recording a resident without consent. 3 out of 3 witnesses denied the observation of another visitor recording a resident without consent. 7 out of 7 staff members interviewed denied the observation of a visitor recording a resident without consent The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded meaning the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. A case management visit was conducted due to a violation observed. See LIC809 on 05/10/2024. This report was reviewed with Interim Executive Director, Christopher Schuster and a copy of the report was provided. Throughout the investigation, 7 staff members were interviewed. Based on interview, 6 out of 7 staff members stated R1 receives showers during his/her shower schedule days. 1 out of 7 staff members was not familiar with R1’s care as R1 was assigned to another group. S1 stated that staff were instructed to wait until R1’s family member arrived before staff could assist R1 with showers. S1 states that sometimes R1 needed to wait to be assisted with a shower if staff were busy assisting other residents. The review of records indicates that R1 is scheduled for showers three times a week. 7 out of 7 staff members interviewed denied restricting any visitors in the facility. 7 out of 7 staff members denied restricting any areas of the facility for visitors. Throughout the investigation, 3 witnesses were interviewed. 3 out of 3 witnesses denied being restricted visitation at the facility. 3 out of 3 witnesses denied the observation of any areas of the facility being restricted for other visitors. The review of records indicates that from October 2023 – December 2023, R1’s care was increased to a total of 65 acuity points and 61 billable points. Care items that were increased from October 2023 – December 2023 included grooming, toileting, assistive devices, outside providers, restless behaviors, verbally disruptive behaviors, delusions and hallucination behaviors, and disturbed sleep behaviors. 7 out of 7 staff members were interviews. Based on interview, R1 required total care and full assistance with activities of daily living (ADL) care. The Department has investigated the above allegations. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Interim Executive Director, Christopher Schuster and a copy of the report was provided. The Department has investigated the above allegation. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. An immediate civil penalty of $500 is being assessed today for serious bodily injury. Additional civil penalties are pending review. A deficiency is being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Interim Executive Director, Christopher Schuster and a copy of the report and appeal rights were provided. PAGE 3 OF 3.the state’s words, verbatim · CDSS document, May 10, 2024 · control 26-AS-20231227155220

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: May 11, 2024

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not ensure to seek timely medication attention for resident (R1) resulting in hospitalization which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 10, 2024

Plan of correction: Licensee will submit a written plan to address the citation issued to LPA Dolores via email by POC due date.

Allegation investigated: Facility staff disclosed confidential information about other residents to a visitor

THIS IS AN AMENDED REPORT FROM 05/10/2024. Licensing Program Analysts (LPAs) Christine Dolores and Grace Donato arrived unannounced to deliver the finding for the above allegation. LPA met with Business Office Director, Francisco Sudiacal. On 01/24/2024, the Department received a complaint alleging staff had disclosed confidential information about other residents to a visitor at the facility. On 02/02/2024, the initial complaint investigation was conducted. The following documents were obtained for this investigation to include resident roster, staff schedule for this week for Memory Care and Assisted Living, R1 – R5’s emergency contact information, physician’s report, individualized service plan, and progress notes from October 2023 – January 2024. SEE LIC9099-C. Unsubstantiated THIS IS AN AMENDED REPORT FROM 05/10/2024. It was alleged that on the first week of December 2023 a staff (S1) randomly shared confidential information to a visitor regarding incidents that occurred with residents - R1, R2, and R3. Throughout the investigation, 7 staff members in Memory Care were interviewed. Based on interview, 7 out of 7 staff denied disclosing confidential information about other residents to a visitor. 7 out of 7 staff denied the observation of another staff member disclosing confidential information to a visitor. Based on interview, the PM shift staff and NOC shift staff conducts meetings in the dining room area between the time of 10:00pm – 10:30PM. This brief meeting is held in the dining room area because of the manager’s office is locked during the nighttime. Staff states that usually there are no visitors around that time, however, if there are visitors around at this time, staff try to be mindful about their endorsements. Throughout the investigation, 3 witnesses were interviewed. Based on interview, 3 out of 3 witnesses denied being shared confidential information about other residents by a staff. 3 out of 3 witnesses denied observing staff share confidential information about other residents to a visitor. Based on interview and record review, S1 was not provided any verbal or written disciplinary actions. The Department has investigated the above allegation. Based on interview, record review and observation the Department has determined the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Business Office Director, Francisco Sudiacal and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 10, 2024 · control 26-AS-20240124171324

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Christine Dolores and Grace Donato arrived unannounced to conduct case management deficiencies visit due to violations observed during a complaint investigation for control number: 26-AS-20231227155220. LPAs met with Interim Executive Director, Christopher Schuster. On 12/26/2023 resident (R1) began to develop flu-like symptoms and was transferred to the hospital on 12/27/2023. Based on staff interviews, staff stated the observation of R1's change of condition on 12/26/2023. On 12/26/2023, the facility did not notify R1’s physician immediately regarding the change of condition. On 12/26/2023 R1’s responsible party contacted the facility around 6:00PM requesting to administer R1 a PRN medication due to verbalized pain and illness. R1’s responsible party spoke with a staff who stated the medtech on duty was currently on lunch and would relay the request when the medtech returns from lunch. Based on interview, the medtech was notified via voicemail, however, the medtechs are not good at listening to their voicemail right away. Based on record review, R1’s PRN medication was not administered until around 8:00PM, about 2 hours after the PRN medication was verbally requested. Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty for repeat violation within a 12-month period is being assessed for the mount of $250. See LIC421FC. This report was reviewed with Interim Executive Director, Christopher Schuster and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 10, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 11, 2024

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not ensure resident (R1) was provided a PRN medication within a timely manner and waited about 2 hours before it was dispensed which poses an immediate health, safety, and personal rights risk to persons in carethe state’s words, verbatim · CDSS document, May 10, 2024

Plan of correction: Licensee will submit a written plan to address the citation issued to LPA Dolores via email by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87466 · Plan of correction due date: May 11, 2024

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. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition 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. Based on interview, record review and observation the licensee did not ensure to immediately inform resident (R1)'s physician of R1's change of condition on 12/26/2023 which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 10, 2024

Plan of correction: Licensee will submit a written plan to address the citation issued to LPA Dolores via email by POC due date.

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Christine Dolores and Grace Donato arrived unannounced to conduct case management other visit due to information obtained during a complaint investigation for control number: 26-AS-20231227155220. LPAs met with Interim Executive Director, Christopher Schuster. LPA's obtained resident (R1)'s progress notes, third party communication, and physician's fax report. This case management visit will be pending additional investigation. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Interim Executive Director, Christopher Schuster and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 10, 2024

Type of visit: Required - 1 Year

On 4/30/24, LPA Grace Donato conducted an unannounced annual visit to the facility. LPA met with Interim Executive Director Christopher Schuster and explained the purpose of the visit.. LPA toured the facility including a random sample of resident apartments, common areas, and kitchen area. LPA observed residents doing exercises in the activity area. While touring the facility it was observed that the temperature was at 78 deg F. Hot water was also tested and the temperature was 110 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Facility has a sprinkler system. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair. LPA. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Facility accepts hospice residents and are in compliance with the required waiver requirements. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. LPA interviewed 5 residents and 4 staff. All residents stated that they are being well taken care of and enjoys the food. All staff are competent with regards to the care of the residents. LPA received the following documents: Liability Insurance, LIC 308. Administrator certificate is pending for review. No deficiencies cited today. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Apr 30, 2024

Allegation investigated: Staff did not administer resident's medication as prescribed. Staff did not notice resident's change of condition.

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding for the above allegations. LPA met with Executive Director (ED) Paula Spanek. On 12/07/2023, the Department received a complaint alleging staff did not administer resident’s PRN medication as prescribed and staff did not notice resident’s change of condition. On 12/14/2023, the initial complaint investigation was conducted. The following documents were obtained to include resident (R1)'s physician's report, appraisal/needs and services plan, progress notes, medication list, MAR from November - December 2023, home health progress notes from October 2023 – November 2023, and correspondence. PAGE 1 OF 3. Substantiated From 02/02/2024 - 02/21/2024, 9 staff members were interviewed. Based on staff interview, staff are to monitor the resident’s bowel movements daily. Staff document their observation in a bowel movement log which is shredded at the end of every month. If a resident were to not have a bowel movement for 3 days, the caregivers are to report to the Medication Technician. The Medication Technicians then follows their procedures which includes but limited to reporting to the facility’s directors, responsible party, and physician. Based on record review R1 is diagnosed with a neurocognitive impairment and is not able to administered own PRN medication. Facility staff assists resident with the administration of all medications. On 11/22/2023, R1’s home health nurse noticed that R1’s last documented bowel movement was on 11/16/2023 and the facility staff was informed of the observation. The review of records show that R1 has a PRN order for constipation medication with instructions to take 1 tablet daily as needed for constipation. From 11/17/2023 – 11/21/2023, there was no documentation regarding the observation of R1's bowel movements. Based on record review, R1 was only administered the PRN medication for constipation on 11/16/23, 11/22/23, 11/23/23, 11/24/23, and 11/25/23. Records show that R1 was not administered a PRN medication for constipation between 11/19/23 – 11/21/23, which counts 3 days after R1 had a last documented bowel movement. Based on staff interview, staff are instructed by R1’s responsible party to inform the responsible party first, before any PRN medications are administered. Based on record review, there are no notes or documentation that R1’s family member was informed that R1 had not had a bowel movement for over 3 days and the request to administer the PRN medication. Based on record review, the facility was also unable to provide documentation that R1's physician was notified of R1's condition of constipation from 11/19/2023 - 11/21/2023, which counts 3 days after R1 had a last bowel movement. PAGE 2 OF 3. Based on staff interview, 9 out of 9 staff was unaware that R1 had gone over 3 days without having a bowel movement. The Department has investigated the above allegations and the preponderance of evidence standard has been met, therefore, the above allegations are substantiated. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Executive Director (ED), Paula Spanek and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 21, 2024 · control 26-AS-20231207102825

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

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: This requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not ensure to assist R1 with a prescribed PRN medication for constipation after it was noted that R1 had not had a BM for more than 3 days which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 21, 2024

Plan of correction: Licensee will provide an in-service training to all staff regarding reporting. Licensee will provide the in-service training document to LPA Dolores via email by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Feb 22, 2024

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. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition 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 interview, record review, and observation the licensee did not ensure that staff documented and informed the resident's physician and family member of their observation of R1's last bowel movement being over 3 days which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 21, 2024

Plan of correction: Licensee will provide an in-service training to all staff regarding proper documents for changes of conditions. Licensee will provide in-service training document to LPA Dolores via email by POC due date.

Allegation investigated: Facility did not report suspected abuse to appropriate agencies within reporting requirements

Licensing Program Analyst (LPA) Christine Dolores arrived to the facility unannounced to open the initial complaint investigation. LPA met with Executive Director (ED), Paula Spanek. On 01/09/2024, the Department received a complaint alleging that the facility did not report suspected abuse within 24 hours to the Department and appropriate agencies. On 01/17/2024, the initial complaint investigation was conducted. The following documents were obtained from the facility to include SOC341s (Report of Suspected Dependent Adult/Elder Abuse) that was sent to the Department from November 2023 – January 2024 and email correspondences. Based on record review, the Department received SOC341s from the facility on 11/27/2023, 12/07/2023, and 12/14/2023. SEE LIC9099-C. Substantiated During visit on 01/17/2024, LPA Dolores was provided SOC341s that were completed on 11/27/2023, 12/06/2023, 12/06/2023, and 12/12/2023. The review of records showed that on 12/02/2023, the facility’s directors were emailed concerns from R1’s responsible party alleging suspected rough handling from staff (S1) to resident (R1) to include unexplained bruises on R1’s arms. Based on interview with staff, the facility did not inform the local law enforcement within 24 hours. The Department also did not receive a report regarding the suspected abuse within the 24 hour reporting requirement. Based on record review, the Department received one SOC341 on 12/07/2023 regarding a visit from the local law enforcement on 12/05/2023. Based on the report, the reason for the visit was to ensure a safety plan was created and followed through to limit the interactions with R1 and a care staff member who R1 did not feel comfortable receiving care from. During visit on 01/17/2024, LPA was provided another SOC341 completed on 12/06/2023, which the Department did not receive. This report alleged that R1 was handled rough by a staff (S1) on 12/01/2023. Based on interview, 1 out of 2 of the SOC341s that was completed on 12/06/2023 was not sent to the Licensing Department because it was a draft. It was stated that the contents of both reports were the same as the report the Department received. Based on observation, the details of both the SOC341s completed on 12/06/2023 contained different contents and information. The Department has investigated the above allegation. Based on interview, record review, and observation the preponderance of evidence standard has been met, therefore, the above allegation is SUBSTANTIATED. A deficiency is being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Executive Director, Paula Spanek and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 17, 2024 · control 26-AS-20240109114455

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(c) · Plan of correction due date: Jan 18, 2024

(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not ensure to report suspected physical abuse of resident (R1) from staff (S1) on 12/02/2023 to the local law enforcement and to the licensing department within 24 hours which poses/posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 17, 2024

Plan of correction: Licensee will review Title 22 regulation Section 87211 and submit a statement of understanding of the section cited. Licensee will also submit an in-service training with the facility director's regarding reporting requirements to appropriate agencies. Licensee will submit both POCs to LPA Dolores by 01/18/2024.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - other visit. LPA met with Executive Director (ED) Paula Spanek. The purpose of the visit was to follow-up on a concern regarding a pending refund for resident (R1), who vacated the premises on 12/28/2023. During visit, LPA interviewed 1 staff member and obtained resident (R1)'s final account statement and Residence and Services Agreement. This case management visit will be kept open and pending investigation. This report was reviewed with Executive Director (ED) Paula Spanek and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 17, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a continuation of a case management – incident visit from 08/04/2023. LPA met with Executive Director, Paula Spanek. On 08/04/2023, LPA Dolores arrived to the facility to conduct as case management – incident visit based on an incident report and death report received for resident (R1). On 08/04/2023, the Assistant Executive Director was interviewed. Documents were obtained throughout the investigation to include resident (R1)’s physician’s report, functional capabilities assessment, individualized care plan, face sheet, progress notes, medical records, fax notifications to physician, police report, verification of death, and death certificate. Based on interview and record review, it was found that on 07/19/2023 resident (R1) was moved from Assisted Living to Memory Care due to a change of condition. Resident was noted to be a fall risk and sustained frequent falls in the community. On the morning of 07/28/2023, R1 sustained a first fall in Memory Care. R1’s family was notified via telephone and physician was notified via fax. The facility did not conduct a re-assessment for R1 after the first fall in memory care. On the night of 07/28/2023, R1 sustained a second fall. Resident did not complain of any pain or discomfort. Staff continued to monitor R1's condition post-fall. Based on record review, there was no indication R1’s family or physician was notified of the second fall. On the night of 07/29/2023, R1 sustained a third fall and was pronounced deceased by the paramedics. Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Executive Director, Paula Spanek and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 1, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a) · Plan of correction due date: Nov 2, 2023

(a) ... The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidence by: Based on interview, record review, and observation the licensee did not ensure to re-assess resident (R1) after sustaining a fall in memory care which poses/posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 1, 2023

Plan of correction: Licensee will submit a statement of understanding of section 87463 and written plan of action going forward to ensure compliance. Licensee will submit the POC to LPA Dolores via email by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87463(b) · Plan of correction due date: Nov 2, 2023

(b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. This requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not ensure to inform the resident's responsible party and physician after resident (R1) sustained a second fall on the same day which poses/posed an immediate health safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 1, 2023

Plan of correction: Licensee will provide an in-service training to staff regarding notification and communications to family and physician's. Licensee will submit the POC to LPA Dolores via email by POC due date.