Oakmont of Silver Creek

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced case management visit for the deficiencies cited on 10/03/2025. LPA was met by Business Office Director (BOD) Mary Ann Bangsal and Memory Care Director (MCD) Abby Castillo. Executive Director/Administrator (ED/ADM) Minnie Weber was unavailable during the time of the visit due to prior commitment. During today's visit (07/23/2026), LPA Partoza, reviewed in-service training and requested copies of the training record. Based on record review, the facility conducted training on he following dates 10/08/2025, 10/22/2025, 11/05/2025, 02/12/2026 02/17/2026, 02/18/2026, 03/26/2026, 04/02/2026, 05/14/2026 for Falls, Changes in condition, Skin tears, Injuries related to residents, Overview of what Dementia is, the different types of Dementia, understanding common behaviors associated with Dementia and appropriate interventions, the importance of early identification and communication of any changes in a resident’s condition, Resident Rights, Reporting Procedures, Review of Individual Service Plans. MCD stated that in addition to the in-service training that management provides, vendors from health services conducts training to facility staff in the memory care unit. No deficiencies were cited during today's visit a copy of the report was provided to Designated Administrator/Business Office Director (BOD) Mary Ann Bangsal and Memory Care Director (MCD) Abby Castillo. end of reportthe state’s words, verbatim · CDSS document, Jul 23, 2026

Allegation investigated: - Staff restrained resident while in care 2 - Staff did not ensure sharps are not accessible to resident 3 - Staff did not provide resident care and supervision, resulting in resident sustaining an injury 4 - Staff did not distribute resident's medication as prescribed 5 - Staff did not ensure that resident's dietary needs were met 7 - Staff did not respond to resident's call alarm system in a timely manner 8 - Staff did not provide housekeeping service when needed 9 - Staff did not provide assistance to resident in care when needed Allegation 6, 10, 11, 12 and 13 are continued in LIC 9099A

This report is being amended due to addtional information received On 05/27/2026 at 1:40 p.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced complaint visit and met with Executive Director (ED/ADM) Minnie Weber. LPA stated the purpose of the visit. ON 09/19/2025, the Department received a complaint with the above allegations (total of 13 allegations). LPA conducted initial investigation on 09/24/2025, interviewed staff and gathered information pertaining to the allegations. Page 1 LIC 9099C Unsubstantiated This report is being amended due to additional information. On 10/15/25, 01/21/26, 01/29/26, 01/30/26, 02/05/26, 02/26/26, 04/30/26, and 05/27/26 LPA conducted inspections visits, and staff interviews. Allegation 1 Staff restrained resident in wheelchair. On 09/24/2025, LPA interviewed reporting party (RP). RP stated resident 1 (R1) required assistance with ambulation; however, staff allegedly avoided assisting R1 by pushing R1’s wheelchair against a wall and placing a table against the wheelchair to keep R1 seated. On 10/15/25, 01/21/26, 01/29/26, 01/30/26, and 03/26/26, LPA interviewed staff 1 through 5 (S1, S2, S3, S5), and former staff 1 (FS1). S1, S2, S3, S5, and FS1 stated R1 required increased supervision, redirection, and monitoring due to fall risk and repeated attempts to stand without assistance. S1 stated residents with mobility instability/unsteady gait may be seated at the dining table while staff assisting residents during mealtime. S2 stated dining tables in the memory care unit were movable and R1 was able to move away from the table. S3, S5, and FS1 stated staff did not use restraint interventions as part of resident care. Five of five staff described R1 as restless and repeatedly attempting to stand from a seated position without assistance, requiring frequent redirection and supervision due to fall risk. S1, S3, S5, and FS1 stated the wheelchair wheels were locked while R1 was seated at the dining table to prevent the wheelchair from sliding and causing injury. S3, S5, and FS1 stated staff did not restrain R1. On 10/15/2025 and 02/05/2026, LPA conducted observations of the memory care dining area. LPA observed the dining tables were movable, chairs allowed wheelchair maneuverability, and tables were not positioned against the wall. On 02/05/2026, LPA did not observe any resident positioned against a wall with a dining table placed in front of the wheelchair. Allegation 2 Staff did not ensure dangerous items were inaccessible to resident On 09/24/2025, LPA interviewed RP. RP stated that on 05/10/2025, staff did not provide adequate supervision to another resident, and RP observed the resident take a knife from the dining room to the resident’s room without staff knowledge. RP stated the incident was reported to staff, who confiscated the knife from the resident. Staff interviews were conducted on 10/15/2025, 01/21/2026, 01/29/2026, 01/30/2026, and 03/26/2026. LPA interviewed S1,S2, S3, S5, and FS1 regarding utensil access and resident safety. S1, S2, S3, S5, and FS1 stated residents were provided standard dining utensils during meal service. S2 stated residents may have access to butter knives used during meals and staff were present assisting residents during mealtime. Five of five staff stated dining utensils were provided during meal service. Staff identified dining utensils as spoons, forks, and butter knives and stated sharp kitchen knives were not accessible to Memory Care residents. Based on documents reviewed, LPA reviewed incident documentation related to the reported knife incident. The Incident Report stated staff retrieved the utensil and no resident injury was reported. page 2 This report is being amended due to additional information Allegation 3 Staff did not provide adequate supervision resulting in resident falls On 09/24/2025, LPA interviewed reporting party (RP). RP stated R1 experienced multiple falls, including incidents on 03/17/2025 and 04/09/2025, resulting in injuries requiring medical evaluation, and alleged staff did not provide adequate supervision. Staff interviews were conducted on 10/15/2025, 01/21/2026, 01/29/2026, 01/30/2026, and 03/26/2026. LPA interviewed S1, S2, S3, S5, and former staff 1 (FS1), who stated R1 exhibited impulsive behaviors, repeatedly attempted to stand without assistance, resisted redirection, and required increased supervision due to declining condition and behavioral changes. Based on documents reviewed, LPA reviewed chart notes, incident reports, assessments, hospice documentation, and care conference records related to R1’s falls and supervision needs. Records reviewed documented falls on 03/17/2025 and 04/09/2025, staff monitoring, behavioral redirection, increased supervision interventions, physician notification, medical evaluation, hospice involvement, and reassessment of R1’s care needs related to R1’s declining condition and fall risk. Documents reviewed stated R1 had repeated attempts to stand without assistance, behavioral changes, fall risk, and increased supervision and redirection needs, as also stated by S1, S2, S3, S5, and FS1. Allegation 4 Staff did not distribute/administer resident’s medication as prescribed On 09/24/2025, LPA interviewed reporting party (RP). RP stated staff did not administer R1’s medications as prescribed, alleging staff overmedicated R1 multiple times, administered additional sedating medications to manage behaviors, crushed R1’s medications without confirmed physician authorization, and reported that on 07/20/2025, R1 consumed medication and later became drowsy. Staff interviews were conducted on 01/21/2026, 01/30/2026, 02/02/2026, and 03/26/2026 to determine medication administration practices and whether medication changes were implemented pursuant to physician orders. LPA interviewed S2, S3, former staff 1 (FS1), and hospice staff (HS). S2 stated medication staff verified the resident’s name, medication label, dosage, and quantity prior to administration. S3 stated medications were administered pursuant to physician orders/directions and could not be started, stopped, or changed without physician direction. FS1 and HS stated R1 experienced physician- and hospice-directed medication adjustments related to R1’s care needs. FS1 and HS stated the medication changes were made as R1’s condition and behaviors changed and were implemented pursuant to physician's direction. page 3 This report is being amended due to additional information received Based on documents reviewed, LPA reviewed Medication Administration Records (MAR), physician medication orders, hospice documentation, Centrally Stored Medication and Destruction Records (CSMDR), and chart notes. Records reviewed documented physician directed medication changes, scheduled medication administration, and PRN medication administration pursuant to physician orders. The Medication Administration Record (MAR) and physician medication orders documented the medications, dosages, and administration instructions prescribed for R1, while chart notes and hospice documentation stated medication changes were made pursuant to physician direction based on R1’s changing care needs. Allegation 5 Staff did not ensure resident’s dietary needs were met On 09/24/2025, LPA interviewed RP. RP stated food was found on R1’s clothing or on the floor, R1 was not consistently assisted with feeding, R1 lacked motor skills to feed independently, and other residents were observed waiting more than an hour for feeding assistance. Staff interviews were conducted on 10/15/2025, 01/21/2026, 01/29/2026, 01/30/2026, and 03/26/2026. LPA interviewed S1, S2, S3, S5, and FS1. S1, S2, S3, S5, and FS1 stated meals were prepared and offered to R1 based on R1’s care needs. S2 stated staff assisted residents who required feeding assistance. S2, S3, S5, and FS1 stated R1 received feeding assistance during meals; S5 stated R1 could eat finger foods independently, and HS stated hospice monitored R1’s dietary intake. Based on documents reviewed, LPA reviewed chart notes documenting R1 ate meals with staff supervision, encouragement to remain seated during mealtime, feeding assistance, and food intake. Chart notes also documented hospice recommendations related to R1’s nutritional care. Record review and interviews documented staff provided meal assistance and monitored R1’s food intake. Documents reviewed did not state R1 had physician-ordered dietary restrictions. Allegation 7 Staff did not respond to resident’s call alarm system in a timely manner On 09/24/2025, LPA interviewed RP. RP stated staff did not timely respond to the monitoring system used in memory care, allegedly turned off pagers, and RP reported having to contact staff regarding R1’s care needs. On 10/15/2025, 01/21/2026, 01/29/2026, 01/30/2026, and 03/26/2026, LPA interviewed S1, S2, S3, S5, and FS1 regarding supervision and alarm-monitoring practices. S1, S2, S3, S5, and FS1 stated residents were monitored through direct supervision, alarm or sensor monitoring, routine checks, and response to resident alerts based on care needs. LPA interviewed S2 and S5. S2 stated resident rooms utilized motion sensors from 8:00 PM to 8:00 AM that notified caregivers through pagers when movement was detected. S5 stated caregivers carried pagers and staff responded based on resident care needs and staff availability. The monitoring system did not maintain staff response-time records for sensor-generated alerts. page 4 This report is being amended due to additional information received Allegation 8 Staff did not provide housekeeping service when needed On 09/24/2025, LPA interviewed RP. RP stated that on 04/05/2025, R1 defecated in R1’s room, smeared feces on the bed, walls, and bathroom, had feces on R1’s face, and was reportedly eating feces. RP alleged the room was not fully cleaned until a later date and the family completed additional cleaning. Staff interviews were conducted on 10/15/2025, 01/30/2026, 02/26/2026, and 03/26/2026. LPA interviewed S1, S3, S6, and FS1. S1, S3, and FS1 stated cleaning services were available when needed. S6 stated the incident occurred after hours and care staff completed initial cleaning prior to S6’s arrival. S6 stated he/she responded in less than one hour, steam cleaned and disinfected the carpet, cleaned the apartment, and laundering of clothing and bedding was completed. Based on documents reviewed, LPA reviewed chart notes and facility records related to the reported incident dated 04/05/2025. Chart notes documented staff observed feces in R1’s mouth, provided hygiene assistance, contacted maintenance for carpet cleaning, and documented maintenance completed carpet cleaning services. Record review and interviews documented staff response and environmental cleaning interventions following the reported incident. Allegation 9 Staff did not provide assistance when needed On 09/24/2025, LPA interviewed reporting party (RP). RP stated R1 did not consistently receive needed supervision, mobility assistance, and behavioral support, resulting in the family obtaining a private 1:1 caregiver due to concerns regarding R1’s care needs. Staff interviews were conducted on 01/21/2026, 01/29/2026, and 01/30/2026. LPA interviewed S2, S3 and S5. S2 & S3 stated staff monitored and redirected residents based on resident needs. S5 stated memory care staff provided supervision, redirection, and behavioral monitoring for residents requiring additional assistance. page 5 This report is being amended due to additional information received Based on documents reviewed, LPA reviewed LIC 602 forms, assessments, care plan records, and chart notes related to R1’s care needs. Records reviewed documented supervision, behavioral monitoring, redirection, mobility assistance, fall prevention interventions, and care planning discussions regarding R1’s increased care needs. Chart notes documented care staff and medication technicians checked on R1 every 15 to 30 minutes, remained with R1 during periods of agitation, redirected R1 during repeated attempts to stand without assistance, and monitored R1 overnight. Record review and interviews documented staff provided supervision and assistance related to R1’s care needs. Chart notes documented that on 04/02/2025 at approximately 9:40 AM, staff monitored R1 during an episode of agitation, and on 04/25/2025 at approximately 6:30 PM, staff assisted and remained with R1 during agitation and repeated attempts to stand to prevent a fall. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited during today's visit for allegations 1 through 4, 5,7,8 and 9, based on the California Code of Regulations (CCR) Title 22. Exit interview was conducted with ED/ADM Minnie Weber and a copy of the report was provided to ED/ADM Minnie Weber. page 6 SEE LIC 9099A of continuation for allegations #6. 10, 11, 12 and 13. Based on documents reviewed, LPA reviewed available staff training records, facility records, assessments, care planning records, and chart notes related to R1’s care needs. Records reviewed documented staff discussions regarding behavioral interventions, supervision needs, resident monitoring, fall prevention interventions, and hospice coordination. Record review and interviews documented staff received training related to resident care and supervision. Allegation 12 Staff did not provide timely notification to responsible party of resident’s change in condition On 09/24/2025, LPA interviewed reporting party (RP). RP stated concerns regarding communication and notification of incidents, condition changes, medical events, and care concerns involving R1. LPA interviewed S1, S2, S3, FS1, and hospice care staff regarding communication practices. S1 stated family meetings occurred regarding R1’s changing care needs and supervision concerns. S2 stated staff notified the physician and responsible party regarding condition changes and completed alert charting related to resident status changes. S3 stated staff notified responsible parties, hospice, and physicians regarding incidents and resident condition changes. FS1 stated facility staff communicated incidents, condition changes, and care concerns to responsible parties. Hospice care staff stated hospice communicated with family and care providers regarding physician-directed care and condition changes. Based on documents reviewed, LPA reviewed chart notes, incident reports, hospice documentation, communication records, assessment records, and care conference documentation related to R1’s condition and care needs. Records reviewed documented communication with responsible parties regarding incidents, falls, medical evaluations, hospice involvement, physician notification, reassessment of care needs, and changes in R1’s condition, including a documented care conference with family on 04/09/2025 regarding supervision concerns, behavioral changes, fall risk, and care planning discussions, hospice evaluation on 04/10/2025, and hospice admission on 04/11/2025. Record review and interviews documented facility staff communicated resident condition changes and care concerns to responsible parties. page 2A Allegation 13 Staff did not distribute/administer resident’s medication properly On 09/24/2025, LPA interviewed reporting party (RP). RP stated concerns regarding medication administration practices, including observations that transdermal medication patches were not consistently removed prior to application of new patches, resulting in concerns regarding improper medication administration. Private Care Giver (PCG) stated observations were made involving multiple transdermal medication patches remaining in place. LPA interviewed S1, S2, S3, former staff 1 (FS1), and hospice care staff regarding medication administration practices. S1 stated hospice was consulted regarding concerns involving multiple transdermal medication patches and staff received follow-up medication reminders. S2 stated medication staff verified the resident’s name, medication label, dosage, and quantity prior to medication administration. S3 stated medications were administered pursuant to physician orders and staff could not independently start, stop, or change medications without physician direction. FS1 and hospice care staff stated medication changes occurred pursuant to physician- and hospice-directed care. Based on documents reviewed, LPA reviewed Medication Administration Records (MAR), physician medication orders, hospice documentation, Centrally Stored Medication and Destruction Records (CSMDR), and chart notes related to transdermal medication administration. Records reviewed documented physician- and hospice-directed medication management related to R1’s care. Records reviewed did not document a physician or hospice statement that retained transdermal medication patches caused increased agitation or other adverse outcome. Records reviewed did not document a written MAR instruction requiring removal of the previous transdermal medication patch prior to application of a new patch. Interviews documented concerns that multiple transdermal medication patches remained in place and that staff received follow-up reminders. Record review and interviews documented medication administration are followed pursuant to physician- and hospice-directed orders. No deficiencies cited during today's visit for allegations 11, 12, 13 based on the California Code of Regulations (CCR) Title 22. Exit interview was conducted with ED/ADM Minnie Weber and a copy of the report was provided to ED/ADM. PAGE 3A Based on documents reviewed, LPA reviewed assessments, chart notes, hospice documentation, incident reports, and care conference records related to R1’s condition and care needs. Records reviewed documented reassessment of R1’s care needs, behavioral changes, falls, medication changes, increased supervision needs, hospice involvement, and care planning discussions regarding R1’s changing condition. Records reviewed further documented a pre-assessment dated 03/14/2025, initial assessment dated 03/15/2025, periodic assessment dated 04/07/2025, hospice evaluation on 04/10/2025, hospice admission on 04/11/2025, and a care conference dated 05/23/2025 regarding R1’s condition and care needs. Allegation 10 Staff did not appraise/reassess resident accurately based on changing care needs On 09/24/2025, LPA interviewed reporting party (RP). RP stated R1’s care needs increased significantly, including increased falls, behavioral escalation, supervision needs, and hospice involvement, and alleged the facility did not appropriately reassess R1’s changing care needs. LPA interviewed S1, S3, and former staff 1 (FS1). S1 stated that when R1 transitioned to the memory care unit on 03/15/2025, facility staff completed an assessment, however, S1 stated he/she do not have a record if staff and former Executive Director (FED) conducted a care conference with the family; FS1 stated R1 was assessed upon transition to memory care and R1’s condition changed over time, requiring increased supervision and care. S3 stated R1’s care needs, supervision needs, and behavioral changes were reviewed as R1’s condition changed. Based on documents reviewed, LPA reviewed assessment records, chart notes, Physician’s Report (LIC 602), care planning documentation, hospice records, and care conference documentation related to R1’s changing care needs. Records reviewed documented reassessment of R1’s care needs, supervision needs, behavioral changes, falls, hospice involvement, and care planning discussions regarding R1’s changing condition. Records further documented a pre-assessment dated 03/14/2025, initial assessment dated 03/15/2025, periodic assessment dated 04/07/2025, hospice evaluation on 04/10/2025, hospice admission on 04/11/2025, and a care conference dated 05/23/2025 regarding R1’s condition and care needs. Records reviewed also documented assessment reviews and care plan updates that were approved, rejected, or refused during the reassessment process dating from 08/11/2022 to 07/01/2025. PAGE 1.2A This agency has investigated the complaint alleging staff did not document observation of resident’s change in condition and staff did not appraise/reassess resident accurately based on changing care needs. We have found that the complaint was unfounded, meaning the allegation was false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited during today's visit for allegation 6 and 10 based on the California Code of Regulations (CCR) Title 22 and a copy of the report was provided to Executive Director/ADM Minnie Weber. PAGE 1.3Athe state’s words, verbatim · CDSS document, May 27, 2026 · control 26-AS-20250919082938

Allegation investigated: Staff did not respond to residents call button.

On 05/27/2026 at 8:05 AM,Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced complaint investigation visit and met with Executive Director/Administrator (ED/ADM) Minnie Weber. LPA stated the purpose of the visit. On 12/17/2025, the Department receive a complaint with the above allegation. On 12/22/2025, Licensing Program Analyst (LPA) interviewed the Reporting Party (RP), who reported concerns that residents experienced delays after activating emergency call pendants. RP stated some residents requiring assistance with escorting, transfers, toileting, and mobility support waited approximately 20 minutes or longer for assistance. LPA reviewed the facility’s pendant call log records dated 12/16/2025 through 12/22/2025, which reflected unresolved and delayed call alert entries. Unsubstantiated On 12/22/2025, LPA interviewed Executive Director (S1), who stated the facility experienced issues involving emergency call pendants during December and replaced affected equipment. S1 stated unresolved call entries may occur when staff physically respond to residents but do not electronically clear the alert. S1 stated the facility utilized escalation monitoring intervals of approximately 5, 10, and 15 minutes, with front desk staff contacting caregivers when alerts remained active. On 02/05/2026, LPA conducted functional testing of six resident emergency call pendants for R4, R5, R6, R7, R8, and R9 in multiple areas of the facility, including the activity room, dining room, and resident hallways. Observed staff response times ranged from approximately 2 to 8 minutes. LPA interviewed residents R4 through R12 regarding staff response to emergency call pendants. 5 out of 9 residents interviewed (R4, R5, R7, R8, and R9) stated staff generally responded within several minutes after activating the emergency call pendant. R6 reported prior pendant relay concerns and stated the pendant had been repaired or replaced multiple times. R10 and R11 stated staff generally responded within approximately 5 to 8 minutes. R12 stated he had not used his emergency call pendant since admission to the facility. On 02/26/2026 and 05/27/2026, LPA interviewed 4 facility staff (S3, S4, S5, and S6), who stated residents activating pendants often require assistance with activities of daily living and mobility assistance. Staff stated unresolved call log entries do not indicate staff did not physically respond to residents because alerts may remain uncleared if staff did not electronically clear the pendant or if the pendant was not responding properly. Based on interviews, record review and LPA observations, 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. No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22 and a copy of the report was provided to Executive Director/Administrator Minnie Weber. page 2 of 2 end of reportthe state’s words, verbatim · CDSS document, May 27, 2026 · control 26-AS-20251217150049

Allegation investigated: Staff did not ensure that facility is delivering hot water for residents in care

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced visit to deliver the finding of the complaint investigation received by the Department and met with Executive Director (ED) Minnie Weber. On 12/17/2025 the Department received a complaint that staff did not ensure that the facility is delivering hot water for residents in care. On 01/21/2026, 02/05/2026 and 02/26/2026 LPA Partoza continued with the investigation and interviewed 12 residents and 3 staff. On 12/22/25, LPA conducted an interview with S1 and collected information regarding water temperature. S1 stated that the plumber came in to check the water temperature when no hot water was reported by the resident and is currently being addressed by the facility maintenance director (MD). page 1 of 4 Unfounded 01/21/2026, LPA interviewed R1 to R3 who stated that the water temperature takes about 3 to 6 minutes to arrive at their faucet and it takes time to reach regulation temperature of 105 to 120. R2 stated that it is not the hot water that's the problem but it's more of "personal preference" according to R2 he/she wants his/her hot water to be at 120 degree F or above, not 105 to 120 degree F. R2 wants hot water to arrive on time when he/she needs it and when he/she wants it and not wait for 5 to 8 minutes for the hot water to arrive through the pipes. R1 stated that it is not the hot water,"it about the length of time before the water rises up to 105 to 120 degrees F. R1 & R2 stated that they are more concerned that water is being wasted. R3 stated he/she just waits. R2 provided LPA a survey that R2 conducted from the facility residents in the assisted living (AL) section. Based on the data collected by R2, he/she was able to get a response from 27 residents out of 32 people who participated in the survey from the AL section of the facility. R2 summarized the survey and found that most of the participants appear content with the hot water temperature in their apartments, with only four or five reporting unsatisfactory water temperature and underlined the phrase "these exceptions need to be more thoroughly investigated." S1 to S3 and R2 stated that on 01/14/2026, R2, ED, MD and the plumber went to 6 of the residents apartments who stated they have no hot water and tested the hot water temperature, S3 stated that the plumber had a bucket and filled it up with hot water and submerged his/her thermometer inside the bucket and the water temperature measure at 118 degree F for the 6 apartments, S3 stated that R2 had his/her own thermometer, measured and made notes and ED shared the results to the residents. On 01/21/2026, LPA conducted a water temperature check of R1 to R3s apartment and was able to measure 109.7 to 118 degree F. in the kitchen and bathroom after 5 to 8 minutes. On 02/26/2026 LPA interviewed R5 and R12 stated that they have no problem with the hot water temperature or the time it takes for the water to rise to proper temperature. R10 and R11 who stated that the water takes time to rise to temperature. R11, stated he/she wants to have hot water that he/she can regulate and that 112 to 118 is not hot enough for him/her. R10 & R11 stated it takes time for the hot water to rise to 105 to 120 degree F. page 2 of 4 Based on interviews, document reviews and observation, this agency has investigated the complaint alleging that "staff did not ensure that facility is delivering hot water for residents in care." 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 based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Executive Director (ED) Minnie Weber and copy of the report was provided. SEE LIC 9099A for the second allegation. page 3 of 4the state’s words, verbatim · CDSS document, Feb 26, 2026 · control 26-AS-20251217150049

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced case management - incident visit and met with Executive Director/Administrator (ED/ADM) Minnie Weber. LPA stated the purpose of the visit. On 12/12/2025, an incident report was received by the Department regarding an altercation between two residents (R1 & R2) who both reside at the memory care unit. R2 was observed wandering the hallway by staff and trying to open residents doors when R2 tried to open the door of R1s room, R1 answered and R2 stated you are in my room and hit R1 on the head. 911 was called and Emergency Medical Team (EMT) responded, but did not transfer R1 to the hospital for evaluation. The facility contacted the police department and was given a case number. During today's visit, LPA requested for the following documents for the two residents. Physician's report (LIC 602), appraisal needs and services plan for both R1 and R2 and other relevant information regarding the incident. ED/ADM stated that a staff (S1) tried to stop R2, but because R2 is a big person and can be aggressive, the staff called for help and another care giver came to assist (S2) to redirect R2. ED/ADM stated that R2 has a one on one care staff 24/7 the day after the incident and family decided to move R2 to a different facility by beginning of the year. At this time, this case in under review and department will conduct a follow up visit , if warranted. No deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22 and copy of the report was provided to ED/ADM Minnie Weber.the state’s words, verbatim · CDSS document, Dec 22, 2025

Allegation investigated: Staff does not ensure resident's injuries are being properly treated. Staff does not communicate with resident's responsible party.

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced visit to deliver the findings of the complaint investigation received by the Department on 07/21/25 with the above allegations. LPA met with Executive Director (ED) Minnie Lacson-Weber. On 07/24/25, the Department conducted an initial 10-day visit and obtained documents. On 07/25/25, the department continued with the investigation and conducted interviews on 07/25/25, 08/07/25 and 08/08/25. 07/25/25 Witness 1 (W1) was interviewed and stated, that on 07/14/25, R1 and W1 had dinner together and R1 was wearing long-sleeved shirt. W1 stated that staff did not report R1s injuries to his/her responsible party (RP) until 07/17/25. A staff approached RP on 07/17/25 and expressed concern regarding R1s injuries. page 1 of 2 Substantiated Staff were interviewed on 08/07/25 and 08/08/25. Staff 1 (S1) stated that on 07/10/25, while attending to R1s needs, S1 and another staff (S2), noticed a purple bruise on R1s right leg shin and notified the medication technician (MedTech) (S3) on-duty. On 07/12/25, while getting R1 ready for the morning, S2 noticed nail marks on R1 left and right arms and hands. S1 stated the nail marks were not there on 07/11/25. S2 then stated to S1 that R1s injury on the right shin “looks really bad.” S1 stated that he/she does not know if S3 or other MedTech reported the injuries to R1s responsible party (RP). S1 also stated that he/she does not know if R1 was taken to his/her physician to be checked. S1 stated that he/she does not know how the injury was missed, because S1 reported the injury right away. Staff 2 (S2) stated that he/she does not document anything during his/her shift. S2 stated that he/she reports verbally any skin issues to MedTech on-duty. On 07/12/25, S2 stated that staff 4 (S4) came to assist and cleaned R1s left and right arm injuries. S2 proceeded to remove R1s pant and sock and discovered that R1s injury on the right shin has worsened. S2 stated the injury was very red, oozing water like gangrene and approximately the size of an apple watch face (42mm). S2 stated “the flesh was growing.” S1 and S2 put a bandage on the injury. S2 did not know if S3 documented the injuries when it was reported. Staff 3 (S3) stated that on 07/12/25, he/she notified his/her supervisor (S7) via text message of R1s arm and shin injury and noted the injuries on the whiteboard but S3 did not report electronically. S3 informed the PM MedTech of R1s injuries to the arms and shin. On 07/18/25, S3 observed the arm injuries were healing, but the right leg shin injury was inflamed and had a pungent discharge. Staff 5 (S5) stated on 07/15/25, nothing was reported regarding R1s injuries and he/she was not aware that R1 has injuries. On 07/17/25, another staff (S8) notified S5 of R1s injuries. S5 stated he/she was very busy and could not attend to R1s injury right away. S5 stated that he/she reported R1s injury to R1s responsible party (RP) when RP came to visit R1 on 07/17/25. S5 stated that on 07/12/25, S3 reported to R1s physician about the injury, but did not document and did not notify RP. S5 stated that the facility has a skin check log and staff are supposed to complete the log and MedTech are supposed to assess skin issues. Page 2 of 3 Staff 6 (S6) stated, on 07/12/25, S6 was notified by S3, that R1 has shin injury and injuries on the arms. S6 cleaned and bandaged R1s arms and observed that R1s shin injury was pink, oval spot that was half the size of a post-it-note. S6 stated he/she did not treat the shin injury because it looked like it's healing. On 07/13/25, S6 reported the injuries to the next MedTech on duty (S10). S6 did not document R1s injuries. On 07/16/25, S6 observed that R1s injuries on the arms were healing but the shin injury turned yellow and was glossy but did not have a foul odor. S6 cleaned and bandage of the shin injury and reported the findings to S3. S6 stated S3 informed S7. On 07/18/25, S5 notified S6 that R1s shin injury was getting worse. S6 stated he/she did not know what to do with R1s injury. S6 feels that he/she did not have enough experience & training to recognize the wound was getting worse. S6 stated that he/she skipped resident health checks due to number of reports that needs to be completed. Staff 9 (S9) stated on 07/12/25 a staff documented R1s arm and shin injuries, however, S9 was not informed until 07/17/25. S9 described R1s right leg shin injury as red, wet and the size of post-it-note, with a faint smell. On 07/17/25, S9 saw skin tears on R1s arms and reported to R1s RP. On 07/17/25 S9 stated that S7, admitted that he/she was aware of R1s injury since 07/12/25 and S7 admitted that he/she did not implement a daily wound dressing change until 07/17/25. S9 stated the facility's protocol for injuries is that MedTech are to follow the chain of command for reporting. S9 stated that S3 reports to S7 who oversees the memory care. S7 did not follow the reporting procedure and did not report to S9. S9 stated that S3 did not properly endorsed injuries to S6 and S3 did not notify and follow up with R1s RP. Based on record review, on 07/12/25, S3 notified S7 and R1s physician regarding the injuries on the left and right forearm. On 07/17/25, S5 notified R1s physician that R1 have a discharge from a wound on the right leg. Based on interviews and document reviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED based California Code of Regulations (CCR) Title 22 87468.2 (a)(4) Additional Personal Rights of Residents in Privately Operated Facilities, 87211(a)(1)(D) Reporting Requirements & 87705(b)(1)(A) Care of Persons with Dementia. See LIC 9099D. Deficiencies were cited during today's visit. An exit interview was conducted with Executive Director, Minnie Lacson-Weber. A copy of the report and appeals rights were provided. page 3 of 3 -- end of reportthe state’s words, verbatim · CDSS document, Oct 3, 2025 · control 26-AS-20250721112622

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

87468.2(a)In addition to the rights listed in Section 87468.1...the elderly shall have all of the following personal rights: (4) To care, supervision...to meet their individual needs and are delivered by staff ...qualifications, & competency to meet their needs. This requirement was not met as evidence by: Based on interviews and document reviews on 07/12/25. S1 to S3 & S5 to S7 did not ensure that R1s wound was treated & addressed in a timely manner to prevent the wound from getting infected. S7 admitted that he/she did not implement daily wound care dressing for R1 until 07/17/25.the state’s words, verbatim · CDSS document, Oct 3, 2025

Plan of correction: ED/S9 stated he/she will conduct in person training, meet with the staff to ensure they are reading & reviewing the rights and care plan of residents. Will have staff review their job description and go over mandated reporting modules for every employee starting 10/8/2025. ED will plan by POC due date of 10/4/25 (cont.) Which pose/poses an immediate health, safety and personal rights risks to persons in care.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 4, 2025

87211(a) Each licensee shall furnish to the licensing agency such reports..including, but not limited to, the following(1) A written report shall be submitted to the licensing agency and to the person responsible...of the occurrence of any of the events specified in (A) through (D). (D) Any incident which (con't.) threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by: Based on interviews and documents review, on 07/10/25 S1 noticed bruising on R1s right shin, S1 reported to S3, however, S3 did not document until 07/12/25 & did not informthe state’s words, verbatim · CDSS document, Oct 3, 2025

Plan of correction: ED/S9 stated will ensure that staff is knowledgeable with the reporting requirment based on their reporting procedures to management, licensing and responsible parties. ED will training on incident reports by 10/8/2025. ED will submit written plan of correction by 10/4/2025 R1's RP. S1 to S3 & S6 to S7 did not follow procedures for reporting requirements as stated by ED. Which pose/poses an immediate health, safety and personal rights risk to residents in care.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(1)(A) · Plan of correction due date: Oct 4, 2025

87705 Care of Persons with Dementia(b) Licensees shall be responsible for...(1)Ensuring staff receive ... training ...specified in Section 87208...(A)Dementia care...knowledge about... skincare, communication...This requirement is not met as evidenced by: Based on interview & record review, on 07/12/2025, S1 to S3, S5 to S7 lacks the comprehension for dementia care, by not addresing R1s wound with proper skincare. There was break in communication by not reporting R1s injuries to R1s RP & to S9 in a timely manner. S6 stated he/she did notthe state’s words, verbatim · CDSS document, Oct 3, 2025

Plan of correction: ED/S9 will conduct an in-service training on dementia 1 on 1 with staff and ANX home health regarding safety, observations of changes in condition, skincare checks & wound checks & reporting to proper chain of command. Target date for training is 10/14/25. ED will submit written plan of correction by 10/4/25 (cont.) have enough training & guidance from S7 to recognize the wound was getting worse. Which pose/poses an immediate health, safety & personal right risks to persons in care.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced annual continuation of the required year inspection and met with Executive Director (ED) Minnie Lacson-Weber and Assisted Living Director (ALD) Anomie De Los Reyes and stated the purpose of the visit. LPA conducted a review of the 6 resident's centrally stored medication record and destruction record (CSMDR). LPA observed that the record was up to date, medications are labeled and matches the physical medication. During the time of inspection and review, LPA observed that record of the medication needs to be readable, organized and located in a timely manner. LPA suggested to ED and ALD to avail of the Department's Technical Support Program (TSP) for record maintenance. LPA verified that the facility conducted fire drill training on the following dates 05/14/2025 and 07/03/2025. ED stated that the earthquake drill will be provided on their next all meeting scheduled on 09/24/2025. No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with Executive Director (ED) Minnie Lacson-Weber and a copy of the report was provided. This concludes the annual required-inspection.the state’s words, verbatim · CDSS document, Sep 18, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted and unannounced Required 1-year inspection visit and was met by Business Office Director (BOD) Mary Ann Bangsal and Maintenance Director (MD) Jaime Martinez. Executive Director/Administrator (ED/ADM) Minnie Lacson-Weber was not present due to prior commitment at the time of the visit. The facility serves adults age 60 and over, capacity of 148 for ambulatory and non-ambulatory and hospice waiver for 15. Upon entry to the facility at 1:10 p.m., LPA observed residents participating on the going activity, some of the residents were in the coffee area, some were in the dining area. LPA observed that hallways, walkways and emergency exits were free from debris and obstruction. LPA was accompanied by the Maintenance Director (MD) while conducting the inspection. LPA inspected the interior of the facility, including but not limited to the entryway, common room, dining room, kitchen and emergency food storage, emergency water storage, laundry room, resident rooms in the assisted and memory care area. LPA conducted an inspection of the facility kitchen and met with executive chef (EC). EC accompanied LPA to the walk-in refrigerator and freezer and the entire kitchen area including the prep area. LPA observed that the refrigerator temperature is at 32 degree F and freezer is at -4 degree F. LPA observed the kitchen to be in sanitary despite of the flurry of activity while preparing for an event. No resident is allowed in the kitchen. LPA observed that the dining area is kept sanitary and organized and open for residents to use. The facility has emergency drinking water supply and emergency food supply that are ready to eat in case of emergency. The facility has 2 days of perishable food and 7 days of non-perishable food. LPA inspected the memory care area and met with the Memory Care Director (MCD). MCD accompanied LPA in inspecting memory care resident rooms. LPA observed rooms were sanitary, and organized, no sharps or chemicals accessible to residents in care, bathrooms were equipped with grab bars and non-slip flooring. The rooms have ample storage to store personal belongings. The room temperature measured at 75 degree F. The memory care area exits is equipped with delayed egress and working audible alarms. The water temperature measured at 105 to 109 degree F. At the time of the inspection LPA observed 3 resident were quarantined in the memory care unit. LPA inspected the assisted living area with MD and inspected random residents room. LPA observed the apartments were organized and sanitary. The bathrooms are equipped with grab bars and non skid flooring. The rooms are equipped with small kitchen appliances such as microwaves and refrigerators. Storage area for the resident's personal belongings. The water temperature measured at 105 to 109 degree F. The facility is equipped with fire alarm system, water sprinkler, carbon monoxide and smoke alarm. The fire system is connected to the fire department. The facility has fire extinguisher that are strategically located on each floor and a main fire hose outside. LPA reviewed the facility resident administrative file and found the files to be complete and updated. The facility maintains the centrally stored medication logs for the residents would require further review. Disaster training will need to be reviewed at a later date. LPA reviewed the staff file such as but not limited to 1st Aid/CPR training certificates, background, personnel report, health screening and training. LPA verified that the record are complete and up to date. Due to time constraint the annual inspection will be continued at a later date. No citations were issued during today's visit based on California Code of Regulation (CCR) Title 22. An exit interview was conducted with Business Office Director Mary Ann Bangsal and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 17, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management Visit and met with Minnie Weber, Executive Director. The purpose of the visit was to deliver two complaints that were under a previous facility license. No deficiencies were cited at this time as per California Code of Regulations, Title 22. This report was reviewed with Executive Director Minnie Weber and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 18, 2025

Allegation investigated: Staff are neglecting resident resulting in falls Facility is short staffed resulting in lack of supervision Facility staff are not cleaning residents room Facility staff are not administering medication in a timely manner Facility staff are not assisting residents during meal time Staff are not repositioning the resident every hour

On 06/04/25 Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced visit to deliver the complaint investigation findings. LPA announced the purpose of the visit and met with Mary Ann Bangsal, Business office director. On 04/23/25 the department received a complaint with the above allegations. On 04/30/25 LPA conducted an initial investigation visit and met with Exuctive Director Holly Suiter. During visit LPA requested 5 residents records, facility housekeeping log, interviewed 10 Staff (S1-S10), and 10 Resident (R1-R10). LPA toured the facility and inspected 7 resident rooms both in the memory and assisted living area of the facility. Page 1 of 3 Unsubstantiated LPA observed 7 out of 7 resident room to be organized and sanitary. LPA interviewed ED who provided the schedule for housekeeping and stated that the resident’s bedrooms are audited daily. ED stated that facility maintains a daily housekeeping log of resident’s room that requires cleaning, and staff will add it to the housekeeping log if needed. LPA observed 4 staff assisting residents in the dining area and 2 staff cleaning rooms. LPA interviewed Staff (S1-S10) 8 out of 10 staff stated that the facility had daily log of rooms that needs cleaning. 3 out 10 staff stated housekeeping does audits of resident rooms to check if they need to be cleaned and if they are not on list staff will still clean the resident’s room. 1 out of 10 staff stated that 1 resident had an accident in the bathroom, and it was cleaned and disinfected in a timely manner. 10 out of 10 staff stated that the residents normally eat in the dining area and only eat in their rooms if they are ill. 8 Out of 10 staff stated that the facility staff encourages to eat and assist them with feeding when staff notices the resident has not touched their food and needs assistance in Memory Care. 2 out of 10 staff stated that the resident’s medication is given to them on time. 3 out of 10 staff states that sometimes residents do not want to wake up early and medication and are given to residents when they wake up. LPA interviewed 10 residents (R1-R10). 2 out of 10 residents stated they have not fallen. 2 out of 10 residents stated that their rooms are always clean, and the staff are attentive to their needs. 2 out of 10 residents stated that their bathrooms are always clean and have not seen any type of smearing on the walls. LPA reviewed 4 resident record and was able to verify that medications are administered to residents based on doctor’s order and administered to them in a timely manner. LPA was present at the facility during the medication pass and observed the medications were given on time. Page 2 of 3 Page 3 of 3 On 06/04/25 LPA interviewed Luisa Lopez Health Services Director and verified that R1 does not have a doctors order for repositioning every hour. Based on observation, interviews and document reviews, the Department has completed its investigation and found that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the above allegation did or did not occur, therefore the above allegations are unsubstantiated. No deficiencies are being cited during today’s visit based on California Code of Regulations Title 22. An exit interview was conducted with Business Office Director Mary Ann Bangal and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 4, 2025 · control 26-AS-20250423070752

Allegation investigated: Staff did not notify resident's authorized representative of incident in a timely manner

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint investigation to deliver the findings on the above allegations. LPA met with Holly Suiter - Executive Director/Administrator On March 15, 2024, the Department received a complaint alleging Staff did not notify resident's authorized representative of incident in a timely manner. On March 13, 2024, the Department received an incident report Regarding resident R1 and R2. The incident report states both residents reside in the memory care unit. Furthermore, on March 6, 2024, at approximately 9:45pm, R1 entered R2’s room and laid in R2’s bed. R2 was using a hospital bed at the time, and R1 laid in the bed not being utilized. R2 came out of his/her room and informed staff that R1 was in his/her room. Page 1 Out of 2. Unfounded On March 22, 2024, LPA Steve Chang interviewed ADM, James Dial. ADM stated on March 7, 2024, he spoke with R2’s authorized representative for 2 hours. LPA Chang interviewed Staff S1. S1 stated Staff S4 called R2’s authorized representative, but no one picked up the phone and could not leave a message. S1 stated he/she spoke with R2’s authorized representative on March 7, 2024, at 3:00pm. LPA Chang interviewed R2’s authorized representative. (AR). AR stated the facility notified him/her about the incident in question, the following day. On November 27, 2024, LPA Manuel Monter interviewed staff S4. S4 stated he/she had called R2’s authorized representative on March 6, 2024, but no one answered. S4 stated she left a voicemail. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 2 Out of 2. LPA Chang interviewed R1. R1 did not respond to LPA’s questions and was unable to provide answers to LPA’s questions. On November 21, 2024, LPA Monter interviewed staff S5-S10. S5 S6 S7 S8 S9 S10 stated R1 has the behavior of trying to enter other residents’ bedrooms. S5 & S8 stated since R1 moved into the facility, he/she has had the behavior of attempting to enter residents’ bedrooms. S5 - S10 stated staff are supposed to redirect R1 if he/she is trying to enter another resident’s bedroom. S5 stated staff are supposed to lock resident bedroom doors to prevent other residents from entering their bedrooms. On November 27, 2024, LPA Monter interview staff S2-S4. S2 – S4 stated R1 has the behavior of entering other residents’ bedrooms. S2 stated on March 5, 2024, he/she was in the activity area/hallway, filling out paperwork in the hallway with staff S3. S2 stated he/she was 5 feet away from R2’s bedroom. S2 stated he/she didn’t see R1 enter R2’s room. S3 stated he/she doesn’t remember what had happened on March 5, 2024. S3 stated “when we don’t have eyes on R1, that is when he/she enters others bedrooms.” S4 stated on March 5, 2024, he/she was in the med room doing his/her end of shift report. S4 stated a staff member had told him/her that he/she couldn’t find R1. S4 stated R1 was then found in R2’s bedroom. On December 5 and 13, 2024, LPA Manuel Monter interviewed staff S1 and S11. Both staff interviewed stated R1 had the behavior of entering other residents’ bedroom. S1 and S2 stated it was one of his/her behaviors, which he/she had since he/she moved in. S1 and S2 stated staff are supposed to redirect R1 when he/she is trying to enter another residents bedroom. A review of R1’s progress notes revealed multiple instances where R1 had entered or attempted to enter other residents’ bedrooms. From the day R1 had moved in, August 16, 2023, till March 6, 2024, R1 had 10 instances of entering another residents bedroom. Based on a review of R1’s Physicians Report, dated August 4, 2023, R1 has a neurocognitive disorder. R1 is also confused and has wandering behavior. Page 2 Out of 3. Based on a review of R1’s individualized Service plan, dated November 29, 2023, R1 has dementia. Under need, the form states R1 wanders into apartment agitating other residents. The form also states the task description for this behavior is to closely observe and guide wandering & to Cue or redirect for safety. Based on a review of a facility incident Report (IR), dated September 13, 2023, R1 was found in resident R3’s room. R3 stated R1 had punched him/her on the face. The IR stated that R3 did have an observable small cut on the inside of his/her upper lip. The Department has investigated the above allegation. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with Holly Suiter - Executive Director/Administrator. A signed copy of this report was provided along with appeal rights. Page 3 Out of 3. END OF REPORT.the state’s words, verbatim · CDSS document, Dec 16, 2024 · control 26-AS-20240315163012

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 17, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(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 was not met as evidenced by; Based on records reviewed & interviews conducted, R1’s has the behavior of entering others residents bedrooms. R1’s care plan states R1 needs to be redirected & wandering guided for his/her safety. R1 entered R2’s bedroom, & staff was informed by R2. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 16, 2024

Plan of correction: ADM stated R1 now has a 1 on 1 care giver from an outside agency, hired by R1's family member. ADM stated she will send a letter of understanding regarding the regulation. ADM stated the plan of correction will be sent by POC date, 12/17/2024.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of a complaint investigation. During the complaint investigation for the complaint 26-AS-20240315163012, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met Holly Suiter - Executive Director/Administrator. On November 21, 2024, LPA Monter interviewed staff S5-S10. All staff interviewed stated R1 has the behavior of trying to enter other residents’ bedrooms. S5 & S8 stated since R1 moved into the facility, he/she has had the behavior of attempting to enter residents’ bedrooms. S5 - S10 stated staff are supposed to redirect R1 if he/she is trying to enter another resident’s bedroom. S5 – S10 stated staff are supposed to lock resident bedroom doors to prevent other residents from entering their bedrooms. LPA observed a resident attempting to enter his/her bedroom but was unable to unlock the door. LPA was interviewing Staff S5 in the hallway when this happened. Staff S5 had already clocked out and when he/she went to ask for a staff members assistance to help the resident enter her bedroom. Staff S9 was brought by staff S5 and unlocked the bedroom for the resident. LPA observed the staff locking bedroom doors and unlocking residents bedroom doors when residents wanted to enter. On November 27, 2024, LPA Monter interview staff S2-S3. S2 & S3 stated R1 has the behavior of entering other residents’ bedrooms. S2 and S3 stated staff are supposed to lock residents bedroom doors. Page 1 Out of 2. On December 13, 2024, LPA Monter interviewed staff S11. S11 stated due to R1’s behavior of entering other residents’ bedrooms, that was the reason why the staff keeps the resident bedrooms locked. S11 stated R1 attempts to enter other residents’ bedrooms at least Once day at least. S11 stated Once resident is taken to dining area, staff locks resident bedroom. S11 stated staff has been doing this since he/she has been working at the facility. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Holly Suiter - Executive Director/Administrator. A copy of the report was provided. Appeal rights were provided. Page 2 Out of 2. END OF REPORT.the state’s words, verbatim · CDSS document, Dec 16, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 17, 2024

87468.1 Personal Rights of Residents in all Facilities (a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by; Based on observation and interviews conducted, facility staff is locking resident’s bedroom doors, requiring residents to ask staff for assistance in opening their bedroom door. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 16, 2024

Plan of correction: ADM stated she will send a written plan of action on how the facility will ensure comfortable accomodations and ensuring residents personal rights, when addressing residents who enter other residents bedrooms. ADM stated she will send a written letter of understanding regarding the regulation. ADM stated she will send the written plan of action by POC date, 12/17/24

Type of visit: Case Management - Other

On 10/18/2024, Licensing Program Analysts (LPAs) Maria (Mita) Partoza and Marcela Yanez conducted an unannounced Case Management-Inspection visit to deliver an immediate exclusion order regarding staff (S1) and met with Mary Ann Bangsal, Business Office Director (BOD). Executive Director/Administrator (ED/ADM) Holly Suiter was in training at the time of the visit was not available. On 10/8/24, the Department conducted an initial visit to investigate the reported incident involving physical abuse to resident (R1).Staff 1 (S1) employment was terminated immediately after the incident happened to R1 which was on 10/3/24. LPAs provided a letter "Order to Licensee/Facility of Immediate Exclusion From Facility" That the department determine that S1 engaged in conduct inimical as a staff in the facility. BOD was informed to remove S1 from any contact with residents and S1 may not be physically present in any facility. BOD stated that S1's employment was terminated immediately after the incident. BOD agreed and understood. The Department issued citation under 87468.1(a)(3) Personal Rights. S1 action towards R1 violated R1's personal rights when S1 pushed R1 away, causing R1 to fall and sustained abrasions on his/her right arm and a contusion and swelling to the back of his/her head. An exit interview was conducted with Business Office Director Mary Ann Bangsal. Appeal rights was discussed and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 18, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Oct 18, 2024

87468.1 Personal Rights of Residents in All Facilities (a)Residents in...residential care facilities for the elderly shall have … the following personal rights: (3) To be free from punishment,…abuse, or other actions of a punitive nature…This requirement is not met as evidenced by: Based on investigation S1 pushed R1 away causing R1 to fall. S1s action towards R1 violated R1s personal rights, which pose/poses an immediate health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 18, 2024

Plan of correction: Business Office Director stated that S1's employment was immediately terminated on 10/3/24 and reported the incident to CCLD, law enforcement, APS and LTCO. ADM stated that they provided staff training on elder abuse.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Maria (Mita) Partoza and Marcella Tarin conducted an unannounced required 1 year inspection visit and met with Business office Director (BOD) Mary Ann Bangsal. Administrator(ADM) Holly Suiter was not present due to required training. LPAs stated the purpose of the visit. The facility is licensed to serve adults 60 and over, 140 ambulatory, 8 non-ambulatory and hospice waiver for 15. At 2:18 p.m. LPA Tarin toured the facility inside and outside with maintenance director (MD) including but not limited to the kitchen, assisted living area, memory care, reception and exterior perimeters and walkways. The temperature inside the facility is at 75 degrees Fahrenheit. The kitchen was observed to be sanitary and organized, knives and sharps were locked and not accessible to residents. LPA observed 2 days of perishable food and 7 days of non-perishable food. The kitchen water temperature measured at 107.9 to 112. 4 degrees Fahrenheit. The bathroom/s are equipped with grab bars, non-skid floors. The water temperature in the bathroom measured at 112.4 degrees Fahrenheit and rooms have sufficient storage. The facility is equipped with a fire, smoke and carbon monoxide alert system that is in good working condition, night lights on the hallway are in good working condition. The hallway are free from obstruction. Fire extinguishers were last serviced 12/15/2023. page 1 of 2, see LIC 809C LPA reviewed 5 resident records such as but not limited to the centrally stored medication and destruction record (CSMDR), admission agreement, needs and services plan, health screening and observed records to be complete and updated. LPA reviewed 5 staff records including but not limited to required training, first aid/CPR training, health screening and background clearance. All staff have criminal record clearance/fingerprints. 3 out of 5 were care providers. 1 Out of 5 is a server and 1 out of 5 is a housekeeper. No deficiencies were cited during today's visit based on California Code of Regulation (CCR) Title 22. An exit interview was conducted with Business Office Director (BOD) Mary Ann Bangsal and a copy of the report was provided. page 2 of 2 end of reportthe state’s words, verbatim · CDSS document, Oct 15, 2024

Allegation investigated: Staff do not follow infection control protocols. Staff do not assist residents with care needs in a timely manner. Staff do not ensure medications are inaccessible to residents. Staff do not maintain complete records for residents.

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced visit to deliver findings regarding the allegation listed above LPA met with Administrator Holly Suiter. On October 7, 2024, the Department received a complaint alleging staff do not follow infection control protocols. It has been alleged staff wearing gloves touching everything. On August 7, 2024, LPA interviewed residents R1-R7. 3 Out of 7 residents (R1,R4,R6) interviewed stated they did not want to be interviewed. 2 Out of 7 residents interviewed (R2 & R5) stated staff wear gloves and throw them away after using them. 2 Out of 7 residents interviewed (R3 & R7) stated they don't know what the staff do regarding their gloves. Page 1 Out of 4. Unfounded LPA interviewed staff S1-S6. 6 Out of 6 staff interviewed stated staff use gloves to assist residents with bathing, showering, toileting and other ADLs. 6 Out of 6 staff interviewed stated when the gloves become stained from use, then staff will dispose of them and get a clean pair. LPA interviewed ADM. ADM stated the facility has plenty of supplies regarding gloves. ADM stated once they have completed their tasks regarding a residents, the gloves should be tossed. During the visit, LPA observed facility staff wearing gloves to assist residents. Once staff finished assisting residents with ADL's or cleaning, staff tossed the used gloves. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Staff do not assist residents with care needs in a timely manner. On October 7, 2024, the Department received a complaint alleging Staff do not assist residents with care needs in a timely manner. On August 7, 2024, LPA interviewed residents R1-R7. 3 Out of 7 residents (R1,R4,R6) interviewed stated they did not want to be interviewed. 1 Out of 7 residents interviewed (R3) stated he/she does not know if staff assist residents in a timely manner. 3 Out of 7 residents interviewed (R2, R5,R7) stated when residents ask for help, staff assist them and don't keep them waiting or delay. LPA interviewed staff S1-S6. 6 Out of 6 staff interviewed stated staff assist residents in a timely manner. 6 Out of 6 staff interviewed stated staff do not delay in assisting residents with their care needs and have not observed any delay. Page 2 Out of 4 LPA interviewed ADM. ADM stated staff provide assistance to residents when requested. ADM stated there has not been any delay to providing care to residents. ADM stated the AM/PM staffing is as follows: 1 medtech 2-3 care staff. 1 activity director, 1 memory care director. ADM stated the night shift has one medtech for memory care and one for assisted living. ADM stated there are 2 care staff in memory care and 1 for assisted living. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Staff do not ensure medications are inaccessible to residents. On October 7, 2024, the Department received a complaint alleging Staff do not ensure medications are inaccessible to residents. On August 7, 2024, LPA interviewed residents R1-R7. 3 Out of 7 residents (R1,R4,R6) interviewed stated they did not want to be interviewed. 3 Out of 7 residents interviewed (R2, R3, R5,R7) stated they have not observed residents medications accessible to residents. LPA interviewed staff S1-S6. 6 Out of 6 staff they have not observed residents medications accessible to residents in care. 6 Out of 6 staff stated residents medications are secured in the medication room, which residents do not have access to. LPA toured the memory care unit inside and out and did not observe any medications accessible to residents in care. LPA observed during tour of the memory care unit's medication room. LPA observed the medication room was locked and inaccessible to residents in care. LPA interviewed ADM. ADM stated, she has not seen any residents medications accessible to residents in care. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.Page 3 Out of 4 Staff do not maintain complete records for residents. On October 7, 2024, the Department received a complaint alleging Staff do not maintain complete records for residents. It has been alleged the facility does not complete any incontinence log. LPA interviewed staff S1-S6. 5 Out of 6 staff interviewed stated staff complete a Bowel Movement log for residents with incontinence and those with doctors orders. LPA interviewed ADM. ADM stated the facility does have charts for ADL's and a bowel Movement log. ADM stated the memory care unit has 19 Out of 21 residents in memory care with incontinence. LPA requested to randomly review 3 residents ADL charts/ BM log. LPA observed the logs to be filled out and complete. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 4 Out of 4. END OF REPORT.the state’s words, verbatim · CDSS document, Oct 8, 2024 · control 26-AS-20241007112136

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced follow up case management visit in regards an incident report, which stated a resident was allegedly pushed by a staff member. LPA's met with Administrator Holly Suiter. LPA's explained the purpose of the visit. On October 4, 2024, the Department received an incident report, regarding resident R1. The incident report stated on October 3, 2024, at approximately 9:30pm, staff responded to a residents behavior in a physical manner. Resident sustained skin tear to elbows, and discoloration to back of head. Staff who responded in physical manner was terminated. On October 8, 2024, LPA's interviewed staff S2 and resident R1. (The Case management dated October 7, 2024, is being amended due to erroneous error made in the LIC809.) LPA determined that the above incident requires further investigation. No deficiencies were cited at this time. This report was reviewed with Administrator Holly Suiter and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 8, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit in regards an incident report, which stated a resident was allegedly pushed by a staff member. LPA's met with Administrator Holly Suiter. LPA's explained the purpose of the visit. On October 4, 2024, the Department received an incident report, regarding resident R1. The incident report stated on October 3, 2024, at approximately 9:30pm, staff responded to a residents behavior in a physical manner. Resident sustained skin tear to elbows, and discoloration to back of head. Staff who responded in physical manner was terminated. On October 7, 2024, LPA's interviewed staff S3 and facility Memory Care Director. LPA's obtained copies of R1's progress notes, physician's report, needs and services plan. Resident R1 had an appointment and could not be interviewed during visit. LPA determined that the above incident requires further investigation. No deficiencies were cited at this time. This report was reviewed with Administrator Holly Suiter and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 7, 2024

Allegation investigated: Staff are not distributing a resident's medications as prescribed

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced complaint investigation viist regarding the above allegations and met with executive director/administrator Holly Suiter and stated the purpose of the visit. On 9/28/2024, LPA interviewed 3 out of 3 staff. 3 Out of 3 staff stated they have 4 medication passes, morning, noon, after dinner and bedtime. The medications needs to be given at the earliest is 1 hour before and the latest is 1 hour after as prescribed by the physician. Page 1 of 2 Unsubstantiated Based on document review of 3 out of 3 resident's medication logs, there was no missed medication or medication not being administered as prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with ED/ADM Holly Suiter and a copy of the report was provided. end of reportthe state’s words, verbatim · CDSS document, Oct 3, 2024 · control 26-AS-20240924143116

Allegation investigated: A resident sustained multiple falls due to neglect and lack of supervision. Residents are not accorded with dignity and respect. Staff are being rough when providing assistance with residents' care.

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced complaint investigation and met with executive director/administrator (ED/ADM) Holly Suiter and stated the purpose of the visit. On 9/19/2024, the Department received a complaint alleging that a resident sustained multiple falls due to neglect and lack of supervision, residents are not accorded dignity and respect, staff are being rough when providing assistance with resident's care. On 9/24/2024, the department received additonal complaint and is being address under complaitn number #26-AS-20240924143116. 09/28/2024. On 9/28/2024, LPA Partoza, conducted an initial investigation and interviewed staff and ED/ADM. page 1 of 2 Unsubstantiated A resident sustained multiple falls due to neglect and lack of supervision. On 9/26/2024, LPA conducted a phone interview with R1s responsible party (RP) and RP stated that R1 does scoot off the bed, tries to get up and thinks that he/she can walk. R1 shakes due to R1s condition. On 9/28/24, from 9:00 a.m. to 12:00 noon, LPA conducted an interview with 4 staff (S1 to S4). 3 Out of 4 staff states that resident (R1) is non-ambulatory, but always tries to get up or scoots off the bed or slides of the wheelchair. 1 out of 4 helps prop R1, when R1 starts to slides of the wheelchair, but did not see R1 fall of a wheelchair. 3 out of 4 stated that R1 is getting checked every two hours, because of R1s history with fall and wanting to get up, staff increased their supervision by checking on R1 every hour. 3 out of 4 staff stated that after 5 or 15 minutes of being checked R1 will be on the floor again. Residents are not accorded with dignity and respect. Based on interview of 4 staff. 4 Out of 4 staff stated that they always respect the resident's personal rights. If they refuse they cannot force the resident. They are free to do what they want and staff supervise or redirect residents. 4 out of 4 stated they care for the resident and they try their best to keep residents active and happy. 4 out of 4 stated they have not seen or witness a resident not accorded with dignity and respect. Staff are being rough when providing assistance with residents' care. Based on interview with 4 staff. 3 Out of 4 staff stated, that there was a caregiver before, who got terminated because of abuse that was a year or more ago, and it's been investigated by the Ombudsman. 4 out of 4 stated they have not seen or witnessed a caregiver be rough with the resident after the incident from last year. Based on document review and interviews, R1 has a condition that contributes to his/her fall due to mental and physical condition and is being addressed on their appraisal needs and services plan. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies are cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with ED/ADM Holly Suiter and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 3, 2024 · control 26-AS-20240919142254

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced pre-licensing inspection visit for changing ownership of the facility, and met with Business Office Director Mary Ann Bangsal (MB) and Memory Care Director Judith Diaz (JD).. LPA checked 5 resident files and 5 staff files with MB and JD. During visit, LPA toured the facility with Maintenance Director Jaime Martinez (JM) to include front desk, the living room, reading room, coffee area, activity room, work room, break room, fitness room, movie theater, restrooms, conference rooms, medications rooms, dinning room, kitchen, laundry room, memory care unit bedrooms, assisted living unit bedrooms and court yard. All fire exits and court yard were free and clear of obstruction. Facility was equipped with fire alarm system and carbon monoxide detectors. JM tested the carbon monoxide detectors, and they were working fine. Facility temperature maintained at 75 degrees Fahrenheit. Hot water was measured at 106 degree Fahrenheit. Fire extinguishers were serviced on 12/23/2022. Two day perishable food supplies and 7 days nonperishable food supplies were observed sufficient. Sharp objects, disinfectants, and chemicals observed locked. Medications rooms and medication carts were observed locked. Component III was conducted with MB. No citations were noted today. Exit interview was conducted with MB. The report was provided to MB for signature. A copy of the report was provided to MB.the state’s words, verbatim · CDSS document, Oct 6, 2023