Oakmont of Valencia

Type of visit: Case Management - Other

Licensing Program Analyst, Mariana Agban arrived on August, 07, 2026 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. On August 10, 2022, the Department concluded a complaint investigation regarding the following allegations: Resident (R1) sustained an unexplained injury for which the staff failed to obtain timely medical care. Due to staff neglect, resident 1 (R1) sustained severe facial injuries. The licensee was cited for California Code of Regulations (CCR) Section ­­-87464(d)­ Basic Services and CCR 87469(c)(3) Advanced Directives and Requests Regarding Resuscitative Measure. At the time of the complaint visit on August 10, 2022, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). (Continue on 809C) The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility failing to properly secure the footrest of the wheelchair and failed to properly secure the Resident in the wheelchair who is known by staff to have a habit of attempting to stand up, resulting in serious bodily injuries to the resident —fractures of both nasal bones and fractures of anterior nasal septum. In addition, the facility staff failed to adequately supervise the resident, resulting in a dislocated shoulder. Staff also failed to provide the resident timely medical attention. Today, August 07th, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500.00 was previously issued on August 10, 2022, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided to facility representative Assaad Zeid and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Aug 7, 2026

Type of visit: Case Management - Other

Licensing Program Analyst Angela Panushkina arrived on August 5th, 2026, for an unannounced inspection to follow up on a substantiated allegation of complaint investigation. On March 29, 2023, the Department concluded a complaint investigation regarding the following allegation: Resident died due to staff administering the wrong medication. The Licensee was cited for California Code of Regulations (CCR) 87466 Observation of the Resident, CCR 87465(g) Incidental Medical and Dental Care, CCR 87411(d)(4) Personnel Requirements - General, CCR 87405(b) Administrator - Qualifications and Duties, and CCR 87463(a) Reappraisals. At the time of the complaint visit on March 29, 2023, an immediate civil penalty of $500 was issued, and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(e). The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that the Department determines resulted in the death of a resident. This is evidenced by the facility failing to provide proper care and supervision after R1 received another resident’s medications that resulted in R1’s death. Continue on LIC809-C Today, August 5th, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(e) for a violation that the Department constitutes as death in the amount of $15,000. However, since an immediate civil penalty of $500 was previously issued on March 29, 2023, the amount of the civil penalty issued today will be $14,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Assaad Zeid and signature on this report acknowledge receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Aug 5, 2026

Allegation investigated: Facility charged a resident for unauthorized services.

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit and met with Executive Director Assaaid Zaid and informed him the purpose of the visit was to deliver the final findings of the investigation. The following information was determined: Concerns were expressed that the facility charged Resident #1 (R1) for unauthorized services. To investigate the allegation, on 08/26/2025, from 9:30 a.m. to 2:00 p.m., (LPA) conducted interviews with staff, and (R1’s) responsible party (RP) involved with R1's care. LPA also obtained and reviewed facility and resident records. LPA made several attempts to contact the reporting party but was unsuccessful in obtaining additional information regarding the allegation. According to records reviewed and interviews conducted, R1 had a series of falls, cognitive decline, and aggressive behaviors. The complaint alleged that R1's family did not consent to one-to-one caregiver services and was charged for those services without authorization. (Cont'd LIC9099C) Unsubstantiated The investigation revealed that R1 was receiving home health services prior to admission, and continued those services one month later, after being admitted to the facility in January 2025. The home health nurse confirmed to LPA that R1 continued to experience falls and increasingly aggressive behaviors. In May 2025, the Executive Director and administrative staff communicated with R1's responsible party and primary care physician regarding R1's declining condition and safety concerns. As a result, R1's insurance provider authorized and funded a treatment plan that included physical therapy, and medication adjustments. Eventually, temporary one-to-one caregiver services was provided for R1. After the authorized services ended, R1's aggressive behaviors and medical decline continued to increase. Facility staff remained in communication with the insurance provider and the (RP) regarding additional caregiver services and discussed alternative placement options that would better meet R1's increasing care needs. The request for additional insurance coverage for caregiver services was denied. Due to the health and safety risks presented by R1's medical decline, the facility initiated private one-to-one caregiver services to protect R1 and other residents. The admission agreement, signed by R1's (RP), authorizes the facility to implement additional services when necessary to address a resident's health and safety needs. Based on interviews, and records review, LPA determined the facility acted appropriately to address R1's health and safety needs in accordance with the terms of the admission agreement. There was insufficient evidence to support the allegation that the facility improperly charged R1 for unauthorized services. It was later revealed to LPA, by the ED, the additional charges for (R1) was subsequently absorbed by the facility. Therefore, the allegation is Unsubstantiated at this time. Exit interview conducted and copy of report provided to ED.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 31-AS-20250818155018

Type of visit: Case Management - Other

At 11:00am, Licensing Program Analyst (LPA) Angela Panushkina conducted a Case Management visit. LPA met with the Administrator and explained the reason for the visit. The visit was conducted to: 1. Amend the original complaint report (control #31-AS-20211018141211) issued on 08/10/2022 due to updated findings. A new revised LIC9099 was created/completed, and an Unsubstantiated report was issued. 2. Amend the original complaint report (control #31-AS-20221110135757) issued on 03/29/2023 to correct an error (typo) in the deficiency listed on page 6. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jun 30, 2026

Type of visit: Case Management - Other

Licensing Program Analyst, Angela Panushkina, arrived on June 11, 2026, for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. LPA met with the Administrator, Assaad Zeid, and explained the reason for the visit. On November 15, 2022, the Department concluded a complaint investigation regarding the following allegation: Resident sustained severe fracture while in care. The licensee was cited for California Code of Regulation Section 87101(c)(3)(F) Basic Services. At the time of the complaint visit on November 15, 2022, an immediate civil penalty of $500 was issued, and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not providing proper care and supervision that resulted in a fall. Residents’ fall was directly and foreseeably caused by staff error and or omission. The pelvic fracture, surgery, and physical rehabilitation are all substantially caused by the same. Continue on LIC809-C Today, June 11, 2026, the Department will be issuing a civil penalty per Health and Safety Code §1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on November 15, 2022, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. The Administrator, Assaad Zeid, and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Jun 11, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Angela Panushkina, arrived on June 11, 2026, for an unannounced inspection to follow up on a substantiated allegation of resident sustained an unexplained injury in care, resident sustained multiple falls due to lack of supervision and facility is not meeting residents’ nighttime supervision needs. LPA met with the Administrator, Assaad Zeid, and explained the reason for the visit. On March 29, 2023, the Department concluded a complaint investigation regarding the following allegations: Resident sustained an unexplained injury in care, Resident sustained multiple falls due to lack of supervision, and facility is not meeting resident's nighttime supervision needs. The licensee was cited for California Code of Regulations (CCR) Title 22, Section 87705(c)(5)(A) Care of Persons with Dementia and CCR Title 22, Section 87705(4) Care of Persons with Dementia. At the time of the complaint visit on March 29, 2023, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not providing proper care and supervision that resulted in multiple fractures from multiple falls. Continue on LIC809-C Today, June 11, 2026, the Department will be issuing a civil penalty per Health and Safety Code §1569.49(f) for a violation that the Department determines constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on March 29, 2023, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. The Administrator, Assaad Zeid, and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Jun 11, 2026

Allegation investigated: Staff are not allowing resident visitations

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit to deliver the final findings of the allegation mentioned above. LPA met with Executive Director Assaad Zeid and informed him the reason of the visit. The following information was determined: Concerns were expressed that staff are not allowing resident visitation. To investigate the allegation, prior to the facility visit on 04/28/2026, between the hours of 9:00 a.m. and 2:30 p.m., (LPA) conducted interviews with the reporting party (RP), facility staff, and other relevant witnesses. LPA also obtained and reviewed pertinent facility and resident records. During the course of the investigation, it was determined that Resident #1 (R1) has a designated Power of Attorney (POA), identified as R1’s daughter. LPA reviewed the POA documentation to verify its validity and scope of authority. Although the POA grants authority to make decisions on behalf of R1, there was no specific documentation outlining restrictions related to visitation. (Con'td LIC9099C) Unsubstantiated Facility staff reported that R1 is non-verbal and unable to communicate effectively. Staff stated that during certain visits, R1 exhibited behaviors such as crying, agitation, and visible distress. Due to these observed behaviors and concerns for R1’s safety and well-being, staff indicated that visitation was limited to common areas to allow for direct observation until R1 was calm and no longer agitated. Based on interviews and records reviewed, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview and copy of report provided.the state’s words, verbatim · CDSS document, May 5, 2026 · control 31-AS-20260421111028

Allegation investigated: Facility staff do not ensure copies of resident records are provided to the residents authorized representative

Licensing Program Analyst (LPA) Tuesday Cabiness met with Executive Director Assaad Zeid and informed him the reason of the visit. Concerns were expressed that facility staff do not ensure copies of resident records are provided to the resident’s authorized representative. To investigate the allegation, prior to the facility visit on 04/28/2026, between the hours of 9:00 a.m. and 2:30 p.m., (LPA) conducted interviews with the reporting party (RP), facility staff, and other relevant witnesses. The LPA also obtained and reviewed pertinent facility and resident records. During the course of the investigation, it was determined that Resident #1 (R1) has a designated Power of Attorney (POA), identified as R1’s daughter. LPA reviewed the POA documentation to verify its validity and scope of authority. (Con'td LIC9099C) Unsubstantiated It was alleged that the facility failed to provide both verbal and written medical information from R1’s primary care physician to the authorized representative. However, based on a review of the legal documentation, including the POA, as well as information obtained through interviews, LPA determined that the facility is acting in accordance with the authority and limitations outlined in the POA. Based on the evidence obtained, and interviews, the allegation is deemed Unsubstantiated.the state’s words, verbatim · CDSS document, May 5, 2026 · control 31-AS-20260501161300

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management regarding an incident report that was received, involving a contracted physical therapist, working for an agency hired by the facility, allegedly exposed private parts to resident # 1 (R1). During the visit, LPA obtained resident records and interviewed staff. At this time, LPA will follow up with additional interviews and obtain police report documentation. Further review is required and LPA will return at a later date and time to gather more information. Also during the visit, LPA obtained documentation involving an alleged resident # 2 (R2) eloping from the facility and the incident was not reported to Licensing. LPA conducted interviews and at this time additional information is required to complete the investigation of failure to report. Exit interview and copy of report provided to the ED.the state’s words, verbatim · CDSS document, Apr 28, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management visit and met with Executive Director Assaid Zeid, informing him of the purpose of the visit. The purpose of today’s visit was to address and gather information regarding an exception request submitted to the Department for approval to retain a resident requiring intravenous (IV) antibiotic treatment. Based on information obtained during today’s visit, the Executive Director (ED) reported that the exception request was submitted on short notice due to a family emergency involving Resident 1 (R1). R1’s family requested that the facility retain the resident for continued treatment while they addressed the emergency. The request was submitted to the Regional Office and was pending review and approval by the Department’s Nurse Consultants. Due to the short notice and the Department not yet issuing approval or denial, the family elected to retain R1 without assistance from the facility. R1 was subsequently re-admitted to the facility on 04/08/2026 without further treatment. During the visit, LPA also addressed recent incidents involving medication errors. According to an incident report dated 02/09/2026, the facility hired a Licensed Vocational Nurse (LVN) through a registry to administer medications. The LVN erroneously administered another resident’s medication to Resident 2 (R2). Following the incident, the LVN was relieved of their duties, and the facility discontinued use of that staffing registry. Regarding a more recent medication error on 04/09/2026, facility staff mistakenly administered medication to Resident 3 (R3). In response, the ED and Health Services Director conducted in-service training and implemented additional staffing during morning and evening medication administration shifts. LPA requested copies of the training documentation and a list of staff who attended. The ED also reported that additional procedural changes will be implemented for newly hired medication technicians. Citation and civil penalty assessed, appeal rights provided, exit interview, and copy of the report to ED.the state’s words, verbatim · CDSS document, Apr 9, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Apr 10, 2026

Incidental Medical and Dental Care:If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff...shall be permitted to assist... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met, evidenced by, based on the SIR, (R1) was not giving medication according to doctor's orders. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: POC cleared during visit. LPA obtained inservice training documents and sign-in sheets for staff all who attended in the training. LPA also requested a current and updated LIC500 to show the staffing schedules for the MC unit during the times medication is being administered to residents for all shifts.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an subsequent annual continuation visit. LPA met with Executive Director Myla Belson and informed her the reason of the visit. On 10/02/2025, during the annual audit inspection conducted from 9:30 a.m. to 3:30 p.m., (LPA) continued the audit review of resident records, specifically auditing centrally stored medication records and conducting a physical count of medications. LPA reviewed medication and records for 14 residents out of 101. The audit revealed discrepancies for 6 residents. Specifically, the initial dates of medication administration did not align with the actual medication counts, resulting in off-count errors. In addition, LPA observed leftover medications from prior monthly cycles, as well as multiple months of overstocked medications that had not been destroyed or returned to the pharmacy as required. These findings demonstrate a improper medication management, including inaccurate record keeping and failure to dispose of or return unused medications, which poses potential health and safety risks to residents. Citation issued//appeal rights, exit interview and copy of report provided.the state’s words, verbatim · CDSS document, Oct 2, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an annual continuation inspection. LPA met with Executive Director Myla Belson and informed her the reason of the visit. During today's visit, from 930am to 230pm, LPA conducted audit review of staff and resident records. For residents, LPA inspected (10) resident files out of (103) residents. Residents records had current physician reports, and needs and service plans. Staff records, LPA reviewed (10) staff files: training records were current and up to date, first aid/CPR certificates were valid, and all staff had criminal record clearances. To complete the annual, LPA will return to audit medication records and resident's medication. Annual inspection is not completed at this time. Exit interview and copy of report provided to ED.the state’s words, verbatim · CDSS document, Sep 23, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an Annual Required visit and inspection of the facility. LPA met with an Executive Director and Myla Belson and explained the reason for the visit. The facility is a large 2 story building with two (2) Memory Care Units (Tradition 1 and Tradition 2). In the main entrance of the building there is a cafe that is a self-serving refreshment and snack area with seating. The main living room has seating and a grand piano for entertainment. There is a reading room and private dining area for family or visitors to use. Smoke detectors/carbon monoxide are hardwired and located throughout the facility. Fire alarms are program to dispatch the Fire Department. Fire extinguishers are located throughout the facility. . Common Areas: Common areas consists of front lobby sitting area, activity rooms, in Assistance Living, and Memory Care Units. All areas are properly furnished, with sufficient room for residents to lounge. Facility also has a beauty salon, gym and a theater for residents. Laundry area is located on a the first and second floor of the facility. Facility has three (3) med-tech rooms, two (2) are located inside the Memory Care Unit and one (1) room is on an Assisted Living side. During today's visit, LPA started reviewing resident files. Due to time constraints, today's annual was not able to be completed. LPA will return at another date and time to continue additional review of resident, and staff files. Also, LPA will continue the physical plant inspection of the facility, which includes residents rooms, common area and kitchen. . Exit interview conducted and copy of report provided to Administrator. During today's visit, LPA started reviewing resident files. Due to time constraints, today's annual was not able to be completed. LPA will return at another date and time to continue additional review of resident, and staff files. Also, LPA will continue the physical plant inspection of the facility, which includes residents rooms, common area and kitchen. . Exit interview conducted and copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Sep 16, 2025

Allegation investigated: Staff are not providing food to resident

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an initial complaint visit, to address the allegation mentioned above. LPA met with Executive Director Myla Belson and informed her the reason of the visit. Allegation: Staff are not providing food to the resident. Prior to the facility visit, on 07/25/2025, from 9:15 a.m. to 10:00 a.m., (LPA) interviewed the complainant regarding the allegation. During an unannounced visit conducted on 07/31/2025, from 9:15 a.m. to 2:30 p.m., LPA interviewed facility staff and residents. Based on the information obtained, it was reported that Resident #1 (R1) receives assistance from a private companion during the night through the following morning. The allegation involves staff allegedly refusing to provide specific breakfast items requested by the private companion on behalf of R1. During interviews, R1 stated that staff provide the requested meals and that food is served accordingly. Interviews revealed that the issue stemmed from interpersonal conflict between the private companion and facility staff, rather than from a failure to meet the resident’s needs. Unsubstantiated Based on interviews, there is insufficient evidence to support the allegation, therefore it's deemed Unsubstantiated at this time. Exit interview conducted and copy of report provided to ED.the state’s words, verbatim · CDSS document, Jul 31, 2025 · control 31-AS-20250723152242

Allegation investigated: Staff does not safeguard resident's personal items

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit, to finish the investigation and deliver the final findings of the allegation mentioned above. LPA met with Executive Director Myla Belson and she was informed the reason of the visit. It was determined: It was alleged that staff did not safeguard Resident #1’s (R1) personal belongings. During the visit, between 930 a.m. and 1:30 p.m., conducted a physical plant inspection, and interviewed staff and residents. From the information obtained, it was reported that some of R1’s personal belongings — including underwear, towels, sheet sets, silverware, and a water bottle — were reported missing, and the facility did not address or resolve what happened to these items. The Executive Director (ED) reported that R1 initially lived in the Assisted Living (AL) unit but was later moved to the Memory Care (MC) unit due to cognitive decline and diagnosis. Staff interviews revealed that some of R1’s items were found and returned. Staff noted that R1 tended to place belongings in unusual locations, such as hallways in the MC unit and outside R1’s door, and staff would return these items to R1’s room. Unsubstantiated To resolve the matter, the ED, along with corporate representatives, offered R1 a monetary gift card so that R1 could replace the missing items. The gift card was accepted. Interviews with other residents indicated they had not experienced missing items and would report it to staff if that occurred. Although some of R1’s belongings were reported missing, evidence suggests R1 often misplaced items throughout the facility, and some were later recovered. In good faith, the ED provided a gift card for replacement of items. Based on the information obtained and interviews conducted, there is insufficient evidence to substantiate the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report provided to the ED.the state’s words, verbatim · CDSS document, Jun 19, 2025 · control 31-AS-20250204090341

Allegation investigated: . Staff do not seek medical attention in a timely manner for resident in care 2. Resident sustained injuries while in care

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit, to deliver the final findings of the allegations mentioned above. LPA met with Executive Director Myla Belson and informed her the reason reason of the visit. The following information was determined: Allegation #1: It was alleged staff do not seek medial attention in a timely manner for resident in care. To investigate the allegation, on June 24, 2024, and during today’s visit, at various times between 9:30 a.m. and 2:30 p.m., the Licensing Program Analyst (LPA) conducted interviews and reviewed relevant documents pertaining to the allegation. Based on the information obtained, Resident #1 (R1) was identified as a fall risk. R1 had a history of multiple falls prior to admission and continued to experience falls while in care at the facility. Documentation reviewed revealed that, on each occasion R1 fell, the facility followed proper procedures, including providing first aid, contacting medical professionals, calling 911, and sending R1 to the hospital when necessary. The facility also notified R1’s family following each incident. Additionally, the facility implemented several measures to reduce the risk of further falls. These included ordering appropriate medical equipment Unsubstantiated and modifying care practices. An overnight care companion, and frequent routine wellness checks were conducted during the day to monitor R1. Therefore, based on interviews and documentation reviewed, there is insufficient evidence to support the allegation. The allegation is determined to be Unsubstantiated at this time. Allegation # 2: It was alleged resident sustained injuries while in care. To investigate the allegation, on June 24, 2024, and during today’s visit, (LPA) conducted interviews and reviewed relevant documentation pertaining to the allegation. Based on the information obtained, Resident #1 (R1) was assessed upon admission and was noted to have pre-existing bruising and wounds. R1 was also identified as a fall risk. According to interviews, R1’s family reported that R1 had a history of falls while living at home prior to admission. After being admitted to the facility, R1 continued to experience multiple falls, resulting in bruising and injuries. Facility staff provided first aid, notified R1’s family and primary care physician, and ensured R1 received medical attention from healthcare professionals. Documentation confirmed that staff recorded the incidents in internal charting notes and submitted Special Incident Reports (SIRs) to Community Care Licensing (CCL). Although it was reported that R1 sustained injuries while in care, the facility responded appropriately by providing timely treatment, notifying responsible parties, and seeking necessary medical evaluation. Therefore, based on the interviews and documentation reviewed, there is insufficient evidence to prove the allegation, and it is Unsubstantiated at this time.the state’s words, verbatim · CDSS document, May 15, 2025 · control 31-AS-20240618151354

Allegation investigated: . Due to lack of staff, residents are not changed timely 2. Due to lack of staff, residents are not getting assistance timely

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit, to deliver the final findings of the allegations mentioned above. LPA met with Excecutive Director Myla Belson and informed her the reason of the visit. The following was determined: Allegation # 1: It was alleged that, due to a lack of staff, residents were not changed in a timely manner. To investigate the allegation, (LPA) conducted interviews and reviewed facility and resident records, as well as other relevant documentation, on the following dates: July 23, 2023; February 29, 2024; December 3, 2024; February 6, 2025; April 24, 2025; and May 8, 2025, between 9:45 a.m. and 3:30 p.m. It was specifically alleged that staff allowed Resident #1 (R1) to remain in urine and feces for a period of time. However, during interviews, residents who require incontinence care reported that staff generally respond to their needs in a timely manner and that they do not have to wait long for assistance. Although some staffing concerns were mentioned, LPA observed adequate staffing levels during each site visit. Unsubstantiated Based on interviews, observations, and a review of documentation, there is insufficient evidence to support the allegation that residents were not changed in a timely manner due to staffing shortages. Therefore, the allegation is Unsubstantiated at this time. Allegation # 2: It was alleged that, due to a lack of staff, residents were not receiving timely assistance. To investigate this allegation, (LPA) conducted interviews and reviewed facility and resident records, as well as other relevant documentation, on the following dates: July 23, 2023; February 29, 2024; December 3, 2024; February 6, 2025; April 24, 2025; and May 8, 2025, between 9:45 a.m. and 3:30 p.m. It was specifically alleged that Resident #1 (R1) was found hanging off the side of the bed without their oxygen mask, and due to staffing issues, R1 did not receive timely assistance, resulting in low oxygen levels. It was also alleged that staff were not aware that R1 had returned to the facility following a hospital discharge. However, it was reported to LPA that the area where R1 resides is secured and requires staff to input an emergency key code to open the door, indicating that staff were aware of R1’s return to the facility. Additionally,interviews revealed that R1 was known to frequently touch their face or move around in bed, which often caused the oxygen mask to become displaced. Staff were aware of this behavior and reported performing routine checks to ensure the mask was properly positioned. Although some concerns regarding staffing were mentioned during interviews, LPA observed adequate staffing levels during each visit. Based on interviews, observations, and a review of facility records, there is insufficient evidence to support the allegation that residents, including R1, were not receiving timely assistance due to staffing shortages. Therefore, the allegation is Unsubstantiated at this time. Exit interview and copy of report provided. Citation issued, civil penalty assessed, appeal rights, and copy of report provided. Plan of correction is cleared, due to facility recent medication training conducted by credential training from the Allen Flores Group on April 8 and 9, 2025. Exit interview conducted.the state’s words, verbatim · CDSS document, May 8, 2025 · control 31-AS-20240221150503

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: May 8, 2025

Incidental Medical and Dental Care:If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff...shall be permitted to assist... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met, evidenced by, based on the SIR, (R1) was not giving inhaler according to doctor's orders. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: POC cleared..Staff received medication training by credential agency, the Allen Flores group on April 8 and 9, 2025.

Type of visit: Case Management - Deficiencies

LPA Tuesday Cabiness conducted a case management visit to follow up on two Special Incident Reports (SIRs) submitted by the facility. The incidents involved (1) a medication administration error, and an un- witnessed altercation between two residents that resulted in minor injuries and police involvement. Incident #1: Medication Error According to the SIR and interview with the Executive Director (ED), Resident #1 (R1) was recently prescribed a new medication, intended to be administered three times per week per the pharmacy label and the physician's written order. However, the pharmacy inputs physician orders for residents in a QMAR system that is able to be be read by the facility, that has description and details on RX's written by the primary physician. According to the QMAR, (R1) was to be administered the new RX once a day. But the RX label wrote (R1) was to be administered the RX, (3x) a week. The error occurred over four days, starting on April 2, 2025. During this period, R1 received the medication daily rather than as prescribed. Staff did not consult the on-duty nurse or verify the dosage instructions with the pharmacy. Once the error was identified, staff immediately informed the Executive Director and the Regional Health Services Director. R1 displayed no adverse reactions but was sent to the hospital for evaluation as a precaution. R1 returned the same day with no new orders. The primary physician and R1’s family were notified of the incident. In response, all medication technicians received credentialed training from the Allen Flores Group on April 8 and 9, 2025. Incident #2: Resident Altercation The second incident involved an un-witnessed altercation between Resident #1 (R1) and Resident #2 (R2). A staff member reported finding both residents on the floor in R2’s room, with each sustaining minor injuries. One resident had a head injury and was transported to the hospital for evaluation. The resident returned to the facility the same day with no new orders. The police were contacted in response to the incident. According to the ED, this was an isolated event between the two residents. There were no witnesses to the altercation, and the facility has taken measures to monitor both residents more closely. LPA will consult with the Regional Office (RO) and facility management regarding the medication error to determine if further action is warranted. At this time, additional review is required. Citation issued, civil penalty issued for repeated violation, appeal rights and copy of report provided to ED.the state’s words, verbatim · CDSS document, Apr 17, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Apr 18, 2025

Incidental Medical and Dental Care:If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff...shall be permitted to assist... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met, evidenced by, based on the SIR, (R1) was not giving medication according to doctor's orders. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 17, 2025

Plan of correction: LPA received training documents from ED that was conducted by a licensed training agency who provided training to all medication technicians working at the facility. POC cleared during the visit.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit to continue the annual inspection. During today's visit, LPA started to review (11) client files and (11) staff records. Medication review and the continuing of resident records will be completed at another date and time. Exit interview and copy of report provided.the state’s words, verbatim · CDSS document, Apr 8, 2025

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

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management visit regarding a Special Incident Report (SIR) that was submitted concerning eight (8) residents who were not administered their prescribed medication. LPA met with Executive Director Myla Belson and informed her the purpose of the visit. According to the SIR, the facility’s medication protocols were reviewed, and the error was identified and addressed promptly. Administrative staff immediately notified the residents' families and primary physicians, and all affected residents were placed under immediate observation. It was reported to LPA that no adverse effects were observed. LPA interviewed staff and the Executive Director and reviewed resident records. Notably, the facility was placed on a non-compliance plan dated 12/15/2022. Additionally, the reports cited the facility for violations related to reporting requirements, resident injuries, unexplained falls, and medication errors, including a questionable death. It was further documented that legal action maybe taken against the facility. Since the date of the Non-Compliance Conference (NCC) on 12/15/2022, and up to today's date, the facility has received six (6) complaints and five (5) case management visits. Two (2) of these visits, on 04/07/2023 and 10/30/2024, involved residents being administered the wrong medication. Another case management visit on 06/24/2024 was related to a failure to report. During today’s visit on 03/27/2025, involved eight (8) residents who missed their daily medication. According to the information obtained, on 03/17/2025, the disbursement of noon medication was missed and not given to residents. Staff identified the error and notified the appropriate administrative staff. Based on today's findings, LPA will recommend that the initial non-compliance plan dated 12/15/2022 be extended for an additional two (2) years and that another (NCC) meeting be scheduled at the local regional office (RO). LPA will discuss recommendations with management, and further review is required at this time and LPA will follow up with the ED. Citation issued, civil penalty assessed, appeal rights, and copy of report provided to ED.the state’s words, verbatim · CDSS document, Mar 27, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(4) · Plan of correction due date: Mar 28, 2025

87411 Personnel Requirements-General; (d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill in the following...Knowledge required to safely assist with prescribed medications which are self-administered... This requirement was not met as evidence by: based on a SIR submitted to Licensing, it was reported (8) residents missed their daily medication. This poses as an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Executive Director (ED) Myla Belson will discuss with the Regional team in regards to training and safeguard implements for staff pertaining to administration of medication and other related training.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(c)(2) · Plan of correction due date: Mar 28, 2025

Incidental Medical and Dental Care:If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff...shall be permitted to assist... following requirements are met:(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met, evidenced by, based on the SIR was submitted: (8) residents were not giving medication according to doctor's orders. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Executive Director (ED) Myla Belson will discuss with the Regional team in regards to training and safeguard implements for staff pertaining to administration of medication and other related training.

Allegation investigated: Staff did not notice residents change in condition

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit, to complete the investigation and deliver the finding for the allegation mentioned above. LPA met with Executive Director Myla Belson and informed her the reason of the visit. The following was determined: To investigate the allegation, on 04/30/2024 and during today’s visit from 9:30 AM to 1:30 PM, the LPA conducted interviews and reviewed facility and resident documents. It was alleged that staff did not notice a resident’s change in condition, and as a result, Resident 1 (R1) developed a urinary tract infection (UTI), which staff failed to detect. Based on the documentation reviewed, R1 was admitted to the facility, and within a few days, R1 was sent to urgent care due to blood in the urine. R1 was diagnosed with a UTI and received treatment. It was reported that R1’s responsible parties were involved and made aware of R1’s medical issues. Throughout R1’s stay, documentation indicated that R1 experienced multiple UTIs and other medical issues. The primary physician and family were involved, and R1 received appropriate treatment. Although it was reported that R1 had a UTI that facility staff was unaware of, the LPA determined that the facility documented Unsubstantiated R1’s condition daily and maintained constant communication with the family and primary care physician. Therefore, based on interviews and documentation, the allegation is Unsubstantiated at this time. Exit interview and copy of report provided.the state’s words, verbatim · CDSS document, Mar 10, 2025 · control 31-AS-20240422110306

Allegation investigated: . Staff did not ensure medication was dispensed as prescribed for resident in care 2. Staff did not ensure resident was properly positioned in bed, resulting in a fall 3. Staff do not ensure infection control policies are maintained

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit, to finish and deliver the final findings to the allegations mentioned above. LPA met with Executive Director Myla Belson and informed her the reason of the visit. The following was determined: Allegation #1: It was alleged that staff did not ensure medication was dispensed as prescribed for a resident in care. To investigate the complaint, on 07/23/2023, 12/03/2024, and 02/06/2025, at various times between 9:45 a.m. and 3:30 p.m., (LPA) conducted interviews and reviewed relevant documents. According to documentation reviewed, Resident #1 (R1) was out of the facility and hospitalized from 06/11/2023 through 06/18/2023 before being discharged and returning to the facility on the same day. Upon R1's return, new medication orders were electronically submitted to the pharmacy. However, the pharmacy required clarification of the prescriptions and contacted R1's primary physician. The facility also reached out to R1’s primary doctor regarding the undelivered medication. The physician’s office clarified the (see LIC9099C-cont'd) Unsubstantiated orders and resubmitted them to the pharmacy. The pharmacy did not receive the updated prescriptions until 06/25/2023, at which point the medication was processed, filled, and delivered to the facility. R1 started the new prescription on 06/25/2023. After reviewing R1’s hospital records, LPA determined that the facility contacted R1’s primary doctor as soon as they became aware that the medication had not been received. R1’s doctor’s office then contacted the pharmacy to verify the prescriptions, and the medication was delivered once the orders were clarified. Therefore, the facility administered the medication according to the doctor’s orders once it was received from the pharmacy. Based on the documentation reviewed, there is insufficient evidence to support the allegation. As a result, the allegation is Unsubstantiated at this time. Allegation # 2: It was alleged that staff did not ensure a resident was properly positioned in bed, resulting in a fall. To investigate the complaint, on 07/23/2023, 12/03/2024, and 02/06/2025, at various times between 9:45 a.m. and 3:30 p.m., (LPA) conducted interviews and reviewed relevant documents. According to the information obtained, Resident #1 (R1) experienced a change in condition, prompting the facility to enroll R1 in its fall management program. LPA received an incident report documenting that R1 had fallen but sustained no injuries. Although it was reported that R1 may have been improperly positioned in bed, there is no evidence to substantiate the allegation. Therefore, based on the information gathered through interviews and document reviews, the allegation is Unsubstantiated at this time. Allegation # 3: It was alleged staff do not ensure infection control policies are maintained. To investigate the complaint, on 07/23/2023, 12/03/2024, and today, 02/06/2025, from various timeframes, between 9:45 a.m. and 3:30 p.m., (LPA) conducted interviews and reviewed documents relevant to the allegation. According to the information obtained, there have been no recent reported cases of residents contracting shingles or exposing others to the infection within the facility. However, it was revealed that Resident #2 (R2) had shingles over a year ago but was quarantined and remained in isolation in their room. Staff reported that meals and medication were provided to R2 in the room to prevent exposure to others. Neither staff nor residents interviewed by LPA reported any instance of a resident walking around the facility with a serious infection. Therefore, based on the interviews conducted, there is insufficient evidence to support the allegation. As a result, the allegation is Unsubstantiated at this time. Exit interview and copy of report provided.the state’s words, verbatim · CDSS document, Feb 6, 2025 · control 31-AS-20230713112552

Allegation investigated: . Staff do not ensure residents are provided feeding assistance 2. Staff do not ensure residents are served food of good quality 3. Staff do not ensure residents are provided bathing assistance in a timely manner

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit and met with Executive Director Myla Belson, and informed her the reason of the visit, which was to deliver the final findings of the allegations mentioned above. The following was determined. Allegation #1: Staff do not ensure residents are provided with feeding assistance. To investigate the complaint, on July 23, 2023, between 10:45 a.m. and 11:45 a.m., (LPA) conducted staff interviews and reviewed documents relevant to the allegation. Today, 12/03/2024, during a follow-up visit from 10:00 a.m. to 4:00 p.m., LPA conducted a physical plant inspection, additional interviews with residents and staff and reviewed resident records. According to the records and information reviewed, Resident #1 (R1) did not require feeding assistance but needed occasional reminders to eat the food presented to (R1). Interviews revealed that (R1) had a private caregiver who often provided reminders, along with staff, to eat but did not need assistance with feeding directly. During today’s observation, LPA witnessed staff providing feeding assistance to residents during mealtimes. This observation further supports the fact that staff are assisting residents as needed. Unsubstantiated Based on interviews, observations, and records reviewed, there is insufficient evidence to support the allegation. Therefore, the allegation is determined to be Unsubstantiated at this time. Allegation # 2: Staff do not ensure residents are served food of good quality. To investigate this allegation, on July 23, 2023, from 10:45 a.m. to 11:45 a.m., (LPA) conducted staff interviews and reviewed documents relevant to the complaint. On December 3, 2024, during a follow-up visit from 10:00 a.m. 4:00 p.m., LPA conducted additional interviews with residents and staff, reviewed resident records, and performed a physical plant inspection. Information gathered through interviews, and a review of the facility’s daily menu, and observations of food served during the visit indicated that the facility provides residents with fresh, quality hot and cold food daily. The resident menu displayed a variety of meal options, with additional choices available. Residents interviewed stated that the food quality is overall good and that they can provide input and suggestions to the chef during monthly Town Hall meetings. Therefore, based on the evidence collected during interviews, and observations, the allegation is Unsubstantiated at this time. Allegation # 3:Staff do not ensure residents are provided with bathing assistance in a timely manner. To investigate this allegation, on July 23, 2023, from 10:45 a.m. to 11:45 a.m., (LPA) conducted staff interviews and reviewed documents relevant to the complaint. On December 3, 2024, during a follow-up visit from 10:00 a.m. to 4:00 p.m., the LPA conducted additional interviews with residents and staff and reviewed resident records. Information obtained during the investigation revealed that Resident #1 (R1) required assistance with showering and dressing. Interviews indicated that (R1) needed the support of two people for these tasks. Additionally, (R1) had a private caregiver who worked (8) to (12) hours daily and frequently assisted facility staff with (R1's) care. The facility maintains a shower schedule, and residents interviewed stated that staff provide assistance as needed. Other residents, who were independent, reported that staff are available when called for help. Based on interviews and documentation reviewed, there is insufficient evidence to prove the allegation, Therefore, the allegation is Unsubstantiated at this time. Exit interview and copy of report provided.the state’s words, verbatim · CDSS document, Dec 3, 2024 · control 31-AS-20230713112552

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: . Resident sustained a fall and injuries while in care 2. Staff failed to seek medical attention for resident in a timely manner 3. Staff left resident unattended for extended periods of time 4. Staff failed to meet reporting requirements 5. Staff failed to protect resident from being harmed by another resident in care

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit and met with Executive Director Myla Belson, and informed her the reason of the visit, which was to deliver the final findings of the allegations mentioned above. The following was determined. Allegation # 1: It was alleged resident sustained a fall and injuries while in care. On 03/29/2023, from 10:30 a.m. to 2:40 p.m., (LPA) conducted the initial investigation, which included interviews, a review of facility and resident records, and a physical plant inspection. During a follow-up visit conducted today from 10:00 a.m. to 2:30 p.m., LPA conducted additional interviews and reviewed resident records. It was reported (R1) had experienced multiple falls at the facility and was assessed as a fall risk. It was reported that (R1) required the use of a walker for ambulation but often needed reminders to use it. Facility records confirmed that staff treated (R1) for a skin tear, notified the Power of Attorney (POA) and primary physician, and facilitated blood work in response to changes in (R1’s) behavior and falls. Although, (R1) did fall and sustained an injury and bruises, LPA determined, the falls were unavoidable due to (R1’s) medical condition and mental state. Unsubstantiated Based on interviews and documentation reviewed, there is insufficient evidence to prove the allegation, therefore, it is Unsubstantiated at this time. Allegation # 2: It was alleged staff failed to seek medical attention for resident in a timely manner. On 03/29/2023, from 10:30 a.m. to 2:40 p.m., (LPA) conducted the initial investigation, which included interviews, a review of facility and resident records, and a physical plant inspection. During a follow-up visit conducted today from 10:00 a.m. to 4:30 p.m., the LPA conducted additional interviews and reviewed resident records. On 03/09/2023, staff discovered( R1) on the bathroom floor following a fall. Staff observed a skin tear near (R1’s) elbow and applied first aid. Staff reported that (R1) did not complain of pain and displayed a full range of motion in both arms and legs. Documentation reviewed by LPA indicated that staff appropriately treated (R1’s) injury and continued to treat and monitor over several days. Documentation also demonstrated that the wounds appeared to be old and healing. Based on documentation and interviews, there is insufficient evidence to support the allegation that staff failed to seek timely medical attention. Therefore, the allegation is Unsubstantiated at this time. Allegation # 3: It was alleged staff left resident unattended for extended periods of time. On 03/29/2023, from 10:30 a.m. to 2:40 p.m., (LPA) conducted the initial visit, which included interviews, a review of facility and resident records, and a physical plant inspection. During a follow-up visit conducted today from 10:00 a.m. to 2:30 p.m., LPA conducted additional interviews and reviewed facility records. Staff and residents both denied staff leave them unattended for extended periods of time. And LPA does not have enough evidence to prove the allegation, therefore based on interviews, the allegation is Unsubstantiated at this time. Allegation # 4: It was alleged staff failed to meet reporting requirements. On 03/29/2023, from 10:30 a.m. to 2:40 p.m., the Licensing Program Analyst (LPA) conducted the initial visit, which included interviews, a review of facility and resident records, and a physical plant inspection. During a follow-up visit conducted today from 10:00 a.m. to 4:30 p.m., the LPA conducted additional interviews and reviewed facility records. It was reported that the facility was not submitting incident reports to the Department’s Complaint Intake Unit. LPA determined that the facility is submitting incident reports to the appropriate local regional office via fax or email. A review of the facility’s profile confirmed that incident reports are being submitted in a timely manner Based on record review, there is insufficient evidence to support the allegation that staff failed to meet reporting requirements. Therefore, the allegation is Unsubstantiated at this time. Allegation #5: It was alleged that staff failed to protect a resident from being harmed by another resident. On 03/29/2023, from 10:30 a.m. to 2:40 p.m., (LPA) conducted the initial visit, which included interviews, a review of facility and resident records, and a physical plant inspection. During a follow-up visit conducted today from 10:00 a.m. to 4:30 p.m., LPA conducted additional interviews and reviewed facility records. According to the information obtained, (R2) denied pushing (R1), while (R1) was vague about the alleged incident and denied it occurred. There were no witnesses that were identified by (LPA) and staff to confirm the incident. Both (R1) and (R2) are no longer residing at the facility. (R1) was relocated to another facility, and (R2) passed away. Based on interviews and documents reviewed, there is insufficient evidence to support the allegation, therefore it is Unsubstantiated at this time. Exit interview and copy of report provided to ED.the state’s words, verbatim · CDSS document, Dec 2, 2024 · control 31-AS-20230321145444

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

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management visit in regards to an SIR (Special Incident Report) that was submitted pertaining to resident #1 (R1) who was administered wrong medication. LPA met with Executive Director Myla Belson, who was informed the reason of the visit, and who reported to LPA, that staff # 1 (S1) accidentally administered the wrong medication to R1. Administrative staff were immediately notified. Power of Attorney (POA) was also notified the same day. R1 was sent to the hospital for evaluation, and was returned to the community, with no documentation of any medical or adverse action of the wrong medication. LPA interviewed staff and Executive Director. The ED reported the incident to Licensing with a SIR. During today's visit, ED reported that the facility and corporate implemented additional medication training, by the Regional Licensed registered nurses that conducted training on October 28, 2024. LPA has determined that further review with the Regional Manager and Licensing Program Manager needs to be followed up at a later date and time. LPA will conduct an additional case management pertaining to the incident of medication error for resident # 1(R1). Citation issued, appeal right, exit interview, and copy of report provided to ED.the state’s words, verbatim · CDSS document, Oct 30, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(4) · Plan of correction due date: Oct 30, 2024

87411 Personnel Requirements-General; (d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill in the following...Knowledge required to safely assist with prescribed medications which are self-administered... This requirement was not met as evidence by: It was reported to Licensing staff #1 administered the wrong medication to resident #1. This poses as an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: An in-service re-training was conducted with medication technicians on 10/28/2024. LPA received by the training record. It was reported that the ED Myla Belson, Rickie McGregor (LVN) and Siliva Anaya (Regional Health Services Director) were present and attended the training. POC will be cleared, but further review will be required upon meeting with management pertaining to medication errors. A follow-up visit will take place at a later date and time.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an Annual Required visit and inspection of the facility. LPA met with an Executive Director and Myla Belson and explained the reason for the visit. LPA toured the facility and observed the following: The facility is a large 2 story building with two (2) Memory Care Units (Tradition 1 and Tradition 2). In the main entrance of the building there is a cafe that is a self-serving refreshment and snack area with seating. The main living room has seating and a grand piano for entertainment. There is a reading room and private dining area for family or visitors to use. Food Inspection: Kitchen and dining area are located on the ground floor of the facility. LPA observed there was sufficient stock of one week non-perishable foods and two days perishable food. Kitchen was observed to be sanitary and free of pests. And emergency food supply was stocked and locked in a storage room. Smoke detectors/carbon monoxide are hardwired and located throughout the facility. Fire alarms are program to dispatch the Fire Department. During the inspection, the building and fire inspectors were at the facility, conducting service, and checking the operation of alarms. Fire extinguishers are located throughout the facility, and were charged. Evacuation drills are conducted twice a year, and the fire drill/disaster are done once a month on every shift. Common Areas: Common areas consists of front lobby sitting area, activity rooms, in Assistance Living, and Memory Care Units. All areas were properly furnished and sanitary with sufficient room for residents to lounge. Facility also has a beauty salon, gym and a theater for residents. Laundry area is located on a the first and second floor of the facility. Facility has three (3) med-tech rooms, two (2) are located inside the Memory Care Unit and one (1) room is on an Assisted Living side. LPA observed all rooms were kept locked and inaccessible to residents in care. Resident Rooms: Rooms consists of single or shared occupancy. A random selection of bedrooms was toured both in Memory Care and Assisted Living. All bedrooms were properly furnished and had appropriate furnishing. Rooms were observed to be sanitary. Bathrooms: Bathrooms were toured and observed to be clean. Nonskid mats and grab bars were observed in all bathrooms. Hot water was measured and was in compliance according to licensing requirements. There is an emergency pull cord located by the toilet. Due to time constraints, LPA was not able to complete the annual inspection. LPA will return to complete a full inspection and audit of resident, staff, and medication records. Exit interview and copy of report provided.the state’s words, verbatim · CDSS document, Oct 30, 2024

Allegation investigated: Staff are not meeting resident's hygiene needs Resident's room is malodorous Staff are not providing adequate laundry service to resident

At 12:30pm, Licensing Program Analysts (LPA), Angela Panushkina and Perchui Milena Khurshudyan, conducted a subsequent visit to obtain additional information and deliver final report. LPAs met with the Executive Director and explained the reason for the visit. During the initial visit, conducted on 05/13/2022, LPA Ruiz requested resident and staff roster. LPA Ruiz also conducted an interview with the (former) Executive Director and staff from 10:00am-12:00pm. Three (3) pictures, relevant to allegations, were also obtained/provided. Additionally, LPA Panushkina requested R1’s medical records dated on 01/03/2022. During today’s visit, LPAs conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 12:50pm - 2:10pm, LPAs interviewed the Executive Director, Culinary-Executive Chef, one (1) MedTech, two (2) staff and six (6) out of ten (10) residents. Continue on LIC9099-C Substantiated Allegation: Staff are not meeting resident's hygiene needs It was alleged that R1 is not getting showers and their hair is greasy and dirty. Moreover, it was reported that R1’s shoes, saturated with diarrhea, were found in the cabinet with R1’s toothbrush. To investigate this allegation, LPA Ruiz conducted an interview with the Executive Director and was informed that Tradition 1 has five (5) staff and Tradition 2 has four (4) staff and a weekly schedule with their assignments are being provided to all staff. Additionally, two (2) staff interviewed confirmed that they receive their assignment, and each staff member is assigned to provide care and supervision to no more than 8 residents and all residents are scheduled to have showers at least twice a week or as needed. Although basic services have been provided to R1 (regarding the showers and diaper change), the facility staff failed to clean R1’s shoes, saturated with diarrhea, which was found in the cabinet with R1’s toothbrush (picture attached). Based on LPAs observation and a picture evidence this allegation is Substantiated. Resident's room is malodorous During the initial visit conducted by LPA Ruiz on 05/13/22 a physical tour was made with the Executive Director. Upon entry into the Memory Care Unit (Traditions 1) LPA and the Executive Director smelled a strong odor of urine. Moreover, when LPA and the Executive Director toured R1’s room #122B they observed that the toilet was clogged, and the room was malodorous. Interview with the Executive Director revealed that she was not aware of the issue. A maintenance order had been placed immediately. Based on LPAs observation, this allegation is deemed Substantiated. Staff are not providing adequate laundry service to resident During the physical plant tour, conducted by LPA Ruiz on 05/13/22, the laundry machines were in working order and laundry services were being provided. However, interviews with the Executive Director and a Memory Care Director revealed that there were having trouble with soap. Staff had reported that soap for laundry was an issue. The facility had already reached out to Eco Lab and complaint of soap leaving stains. Based on interviews and picture evidence this allegation is Substantiated. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC9099-D. Exit interview conducted, appeal rights explained and copy of this report signed and delivered. Allegation: Staff left resident in soiled diapers for extended period of time It was alleged that R1 was left in saturated diapers with feces and urine in bed. During the initial visit, conducted by LPA Ruiz, interview with the Executive Director, Memory Care Director and staff were made. At that time, LPA was informed that R1 was diagnosed with Dementia and wore adult diapers due to urinary incontinence. Two (2) staff interviewed denied that R1 was left in soiled diapers for an extended period of time. S1 stated that R1's diaper was constantly changed throughout the day and that R1 was given a bath two (2) times per week. LPA was also informed that all incontinent residents are scheduled to be changed every two hours or as needed. In addition, during today’s visit, LPAs conducted an interview with six (6) out ot ten (10) residents and all residents interviewed expressed no concerns regarding the above allegation. Lastly, during the interviews and physical plant tour, LPAs observed all residents looked clean and well taken care of. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is Unsubstantiated at this time. Allegation: Staff are not providing adequate food service to resident's It was alleged that facility staff failed to provide adequate food service by serving residents food that they can't cut. To investigate this allegation, LPAs conducted an interview with the Culinary Executive Chef and two (2) staff members. All parties interviewed informed LPAs that the facility provides three (3) nutritious meals and snacks in between. Moreover, the Executive Chef informed LPAs that the kitchen area has a board with residents pictures/names that require special diet and the facility always follows doctors orders. In addition, LPAs were informed that protein (chicken, meat, fish) is always being chopped prior to be served to all residents. Two (2) staff interviewed corroborated the Chef's statement and informed LPAs that they always assist Memory Care Unit residents with cutting their meals upon request. Lastly, interview with six (6) out of ten (10) residents expressed no concerns of the food services. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff not providing an adequate food service to residents. Therefore, the allegation is deemed Unsubstantiated at this time. Continue on LIC9099-C Allegation: Staff are not safeguarding resident's personal belongings. It was alleged that R1's clothes had gone missing. To investigate this allegation, LPA Ruiz conducted an interview with the Executive Director, Memory Care Director and staff, during the initial visit. All parties interviewed denied the above allegation. LPA Ruiz was informed that due to R1's diagnoses, R1 would misplace his/her personal belongings. Nothing has been brought up as missing. LPA was also informed that once the management makes aware of this type of an issue, all staff gets notified and the facility starts a search. Most of the time (95%) the residents misplace their belongings and the staff finds and returns it to them. Six (6) out of ten (10) residents interviewed, during today's visit, expressed no concerns regarding the above allegation. Based on the information obtained this allegation is deemed Unsubstantiated at this time. Allegation: Resident was severely dehydrated To investigate this allegation, LPA Ruiz, conducted an interview with the Executive Director and staff during the initial visit. All parties interviewed revealed that they always keep juice and water next to R1’s bed and that R1 was drinking fluids regularly. A review of medical records from the hospital did not reveal any information to verify that at the time of admission to the hospital (in January 2022) R1 was dehydrated. Based on interviews and record reviews, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Aug 28, 2024 · control 31-AS-20220506153855

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 4, 2024

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... This requirement is not met as evidenced by: Based on LPA Ruiz inspection, during the initial visit, the licensee did not comply with the section cited above. Staff failed to clean R1’s shoes, saturated with diarrhea, which was found in the cabinet with R1’s toothbrush This poses/posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 28, 2024

Plan of correction: Administrator will have in-service training with all staff and submit copy of the proof to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Sep 4, 2024

Managed Incontinence: (b) In addition to Section 87611... the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry, and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on LPA Ruiz inspection/observation, during the initial visit, licensee did not comply with the section cited above by having a strong odor of feces/urine in room #122B and Memory Care Unit. This poses/posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 28, 2024

Plan of correction: Administrator will have in-service training regarding this section. Proof of training will be submitted to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(C) · Plan of correction due date: Sep 4, 2024

Personal Accommodations & Services: (a) Living accommodations and grounds shall be... Equipment and supplies necessary for personal care and maintenance of adequate hygiene... (C) Clean linen… shall be in good repair. This requirement is not met as evidenced by: Based on interview/observation conducted by LPA Ruiz, licensee did't comply with the section cited above by purchasing a laundry detergent that damaged residents personal items; clothing, bedsheets, which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 28, 2024

Plan of correction: Administrator shall conduct an in-service training to housekeeping regarding residents' laundry. Submit copy of training, with staff's signatures, as proof of attendance, to LPA

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a Case Management, in conjunction with complaint control # (31-AS-20240618151354). According to information obtained during the preliminary of the investigation, it was reported that resident #1 (R1) had sustained multiple falls at the facility. LPA reviewed incident reports submitted by the facility, and LPA observed that one SIR (special incident report) was submitted pertaining to R1 falling on 06/17/2024. It was revealed to LPA that R1 fell twice, either once on 06/16/2024 or twice on 06/17/2024. The initial SIR reported, R1 fell once on 06/17/2024. Therefore, based on documentation and interviews, the facility failed to report R1 falling twice. This is a potential health and safety risk to residents in care. Citation issued and incident submitted to LPA during visit. POC cleared. Exit interview, citation, appeals, and copy of report provided.the state’s words, verbatim · CDSS document, Jun 24, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jun 28, 2024

Reporting requirements; (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1)A written report shall be submitted to the licensing agency...and to the person responsible for the resident within seven days ...and disposition of the case. This requirement was not met evidenced; based on documentation and interviews, facility submited one SIR for R1 when there were multiple falls. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 24, 2024

Plan of correction: Executive Director (ED) will submit incident report for fall dated on 06/16/2024. During visit, LPA received SIR, and POC is cleared.

Allegation investigated: . Facility did not make sure residents have hot water 2. Residents’ incontinence needs are not being met 3. Residents’ bathing needs are not being met 4. Facility did not make sure elevator was in working condition

Licensing Program Analyst (LPA) Tuesday Cabiness conducted today's subsequent visit to amend report that was originally created on 04/30/2024. The original document was missing pertinent verbiage that should have been documented on the report. LPA met with Executive Director Myla Belson and informed her the reason of the visit. Allegation # 1: It was alleged facility did not make sure residents have hot water. On 01/19/2024, (LPAs) Gary Tan and Michael Cava conducted a physical plant inspection, interviewed staff, and obtained documents pertaining to the complaint. During today’s visit, from 1030am to 2pm, LPA Tuesday Cabiness conducted additional interviews, and reviewed documents pertaining to the allegation. It was reported, the facility did have plumbing issues, and certain resident’s rooms water temperature was low. The Executive Director (ED) contacted the family, reported to Licensing, notified residents and their family. Facility used vacant rooms, to ensure residents had hot water and their personal hygiene needs were met. Unsubstantiated Although the facility did not have hot water in various resident rooms, the ED contacted a plumbing company and the issue was resolved, and there were vacant rooms for residents to use for hot water use. Also, the entire facility was not impacted of not having hot water. Therefore, based on documentation and interviews, the allegation is Unsubstantiated. Allegation # 2: It was alleged residents’ incontinence needs were not met. On 01/19/2024, (LPAs) Gary Tan and Michael Cava conducted a physical plant inspection, interviewed staff, and obtained documents pertaining to the complaint. During today’s visit, from 1030am to 2pm, LPA Tuesday Cabiness conducted additional interviews, and reviewed documents pertaining to the allegation. It was reported, the facility did have plumbing issues, and certain resident’s rooms water temperature was low. Although there were various resident’s rooms that had no hot water, the facility notified all the proper representatives and family and utilized vacant rooms for residents to use, therefore resident’s incontinent care needs was provided for. Based on documentation, the allegation is deemed Unsubstantiated at this time. Allegation #3: It was alleged residents’ bathing needs are not being met. On 01/19/2024, (LPAs) Gary Tan and Michael Cava conducted a physical plant inspection, interviewed staff, and obtained documents pertaining to the complaint. During today’s visit, from 1030am to 2pm, LPA Tuesday Cabiness conducted additional interviews, and reviewed documents pertaining to the allegation. It was reported, the facility did have plumbing issues, and certain resident’s rooms water temperature was low. Although there were various resident’s rooms that had no hot water, the facility notified all the proper representatives and family and utilized vacant rooms for residents to use, so personal hygiene, such as showering, bathing and toileting were met. Therefore, based on documentation, the allegation is deemed Unsubstantiated at this time. Allegation # 4: It was alleged facility did not make sure elevator was working condition. On 01/19/2024, (LPAs) Gary Tan and Michael Cava conducted a physical plant inspection, interviewed staff, and obtained documents pertaining to the complaint. During today’s visit, from 1030am to 2pm, LPA Tuesday Cabiness conducted additional interviews, and reviewed documents pertaining to the allegation. According to information obtained, during the visit with (LPAs) Tan and Cava, it was reported that to them by the ED Myla Belson, that one of the wires got caught which caused the elevator to stop operating. Staff were instructed to stay at the stairwell for the residents that needed assistance coming up or downstairs. Although it was reported facility did not ensure the elevator was working, the ED contacted an elevator company, and the issue was resolved within a couple of hours. Facility took proper safety measures for the residents, therefore at this time, the allegation is deemed Unsubstantiated. Exit interview and copy of report provided.the state’s words, verbatim · CDSS document, Apr 30, 2024 · control 31-AS-20240111135934

Type of visit: Case Management - Other

At 10:00am, Licensing Program Analyst (LPA), Angela Panushkina conducted a Case Management visit to Amend the following reports: Complaint Control #31-AS-20230608081726, visit date conducted on 06/15/23 Case Management Incident visit date conducted on 06/15/23 Exit interview conducted and copy of this report signed and deliveredthe state’s words, verbatim · CDSS document, Mar 20, 2024

Allegation investigated: Staff are mismanaging resident's medication log.

At 10:00am Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent complaint visit to deliver the finings for the above stated allegation. LPA met with the Executive Director, Myla Belson, and explained the reason for the visit. During the visit made on 12/14/22, LPA spoke with the former Executive Director, Resident Care Coordinator, two (2) staff members, two (2) MedTechs and five (5) residents. LPA also obtained copies of pertinent documents relevant to the investigation. LPA also reviewed the facility Centrally Stored Medication and Destruction Records (CSMDR) of random residents receiving medication assistance by the facility staff. Upon review of the medications LPA observed that three (3) out of three (3) randomly chosen residents prescribed medications were centrally stored by the facility. LPA also observed that each resident has an individual, labeled basket for their medications. Interviews with three (3) MedTech’s revealed that they dispense Continue on LIC9099-C Unsubstantiated medications for one resident at a time. All MedTech’s informed LPA that once resident takes the medication, MedTech initials the Medication Administration Record (MAR) log. LPA was also informed that when the resident refuses to take the medication the staff member writes a comment/reason in MAR log as to why the medication was not taken. Based on review of the facility medication records for the months of September, October and November 2022, for three (3) out of three (3) residents, all documents appeared to be completed to its entirety including medication name, strength, instruction control, date filled, etc. Based on the interviews conducted and documentation reviewed, there is not enough substantial evidence or witnesses to concur with the allegations. Therefore, this allegation is deemed Unsubstantiated at this time. No deficiency cited during todays visit. Exit interview conducted and copy of this report provided to the Executive Director.the state’s words, verbatim · CDSS document, Mar 18, 2024 · control 31-AS-20221208085425