Oakmont of Westpark

Allegation investigated: Facility does not provide appropriate toilet to meet resident's toileting needs.

Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced to do complaint investigation. LPA met with Administrator Barbara Fleck during today's inspection. The department conducted a record review and interviewed residents and staff regarding the allegation. Documentation showed that on or around 7/7/26, Resident R1 contacted the concierge with concerns about the water level in their toilet and requested that it be lowered. Maintenance was notified and responded the same day. The maintenance technician attempted adjustments to reduce the water level; however, due to the type of flush system in place, it could not be effectively lowered. A new flushmate system was installed, but the water level remained unchanged. Staff offered to provide a commode as an alternative, but R1 declined and requested a toilet riser, asking that the facility cover the cost. The LPA confirmed that a toilet riser has since been installed and the concern has been resolved. Based on the information obtained, this allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted and a copy of this report was provided. Signature on these forms acknowledges receipt of these documents. Unfoundedthe state’s words, verbatim · CDSS document, Sep 2, 2026 · control 59-AS-20260715141755

Allegation investigated: Staff did not ensure that resident's call button is operable. Staff did not provide comfortable accommodations for a resident in care.

Licensing Program Analyst (LPA) Bethany Mirlohi arrived to deliver complaint findings. LPA met with Administrator Barbara Fleck during today’s investigation. LPA investigated allegation, “Staff did not ensure that resident's call button is operable”. Relevant party indicated that R1’s call button does not always work because staff at times do not respond. LPA interviewed administrator in which she stated that R1 uses their call light frequently throughout the day and it is recorded. R1 reported to administrator that one night their call light was not working. Administrator reviewed the call light log and it did not show a call being initiated by R1. Administrator and the ombudsman tested R1’s call light, and it was found the first attempt of R1 pressing their pendent did not work. Once administrator instructed R1 to press and hold the call light button until a beep sounded, then R1 successfully used their pendent. LPA reviewed the call light log for R1 for the month of May and found that R1 uses the call pendent frequently and it was in working order. Due to the information gathered, LPA finds allegation to be unsubstantiated. Unsubstantiated LPA investigated allegation, “Staff did not provide comfortable accommodations for a resident in care”. R1 indicated that their toilet seat is uncomfortable and pokes them. LPA interviewed administrator in which she stated that R1 reported to her that the toilet seat was uncomfortable and she sent maintenance to R1’s room to look at the issue. LPA interviewed a relevant party in which they stated R1 reported to them the issue was fixed by the maintenance team. Due to the information gathered, LPA finds allegation unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 2, 2026 · control 59-AS-20260514173908

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with Administrator Barbara Fleck during today's inspection. LPA arrived to review an incident report received by the facility. On 6/13/26 medication technician(med tech) gave a hospice resident (R1) the wrong amount of medication. Hospice prescribed R1 1ml of morphine every 1 hour, and med tech gave R1 2ml of morphine every 1 hour for 7 doses. Family and hospice were notified of the medication error and resident was monitored. Administrator reported med tech no longer works at the facility and training was completed for all staff dispensing medication. Deficiencies cited on 809-D. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 14, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 15, 2026

87465(a)(4) Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self administered medications as needed. This requirements was not met by evidenced by: Medication was given incorrectly to residents in care. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 14, 2026

Plan of correction: Administrator has completed training with staff regarding medication error. Administrator provided LPA a copy of training that was given.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct case management. LPA met with Administrator Barbara Fleck during today's inspection. During today's inspection LPA arrived to review an incident report that was sent into CCL. LPA interviewed administrator and staff and reviewed resident file. No further information is required for this incident report. At the time of this visit no deficiencies were given. Exit interview and report provided.the state’s words, verbatim · CDSS document, Jun 11, 2026

Allegation investigated: Staff left resident in soiled briefs for extended period of time Staff did not report incidents to responsible party

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint investigation findings. LPA met with Lisa Velasco during today’s inspection. LPA investigated allegation, “Staff left resident in soiled briefs for extended period of time”. During the complaint investigation LPA reviewed resident documentation, hospice documentation, conducted a tour, and interviewed staff. On 1/29/26 LPA toured the memory care unit and observed residents engaged in an activity while others were still eating in the dining room. LPA observed residents looked well groomed and comfortable. During the tour LPA observed no foul odor and residents rooms appeared clean and organized. LPA reviewed R1’s hospice documentation and observed one occasion resident was found to be soiled however LPA was unable to determine for how long. LPA reviewed R1’s facility documentation and found resident required continence care but no issues were documented. Continuation on 9099-C. Unsubstantiated LPA interviewed relevant party in which they stated they observed R1 saturated with urine several times. LPA interviewed 4 care staff who helped R1 with care, and they stated they changed R1 every 2 hours or as needed. No care staff reported issues with R1’s continence care. Due to the information gathered LPA finds allegation to be Unsubstantiated. LPA investigated allegation, “Staff did not report incidents to responsible party”. LPA reviewed hospice and facility information and interviewed relevant party and staff. LPA reviewed hospice documentation and observed there were no concerns with facilities reporting. LPA reviewed facility documentation, in which staff documented several incidents and each time it was documented that family and hospice were notified. LPA interviewed relevant party in which they stated there were several times that facility did not report to R1’s family concerning incidents and only found out through hospice. LPA interviewed 4 care staff in which they stated whenever something occurred with R1 they would report the issue to the family and hospice immediately. Care staff had no concerns with reporting incidents to families. Due to the information gathered LPA finds allegation to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview was conducted.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 59-AS-20260127102741

Allegation investigated: Staff did not issue an appropriate refund to resident’s authorized representative Staff do not respond to resident's call for assistance in a timely manner Staff did not clean resident’s room

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint investigation findings. LPA met with Administrator Barbara Fleck during today’s inspection. LPA investigated allegation, “Staff did not issue an appropriate refund to resident’s authorized representative.” LPA conducted interviews with relevant parties and staff and reviewed resident documentation. LPA interviewed relevant party in which they stated that R1 paid in advance for care, and so when R1 passed on the 5th and all personal belongings were removed on the 7th of the month last year, R1 was due for a refund. R1’s estate was issued a refund, but money was taken out for carpet replacement and tray services. Relevant party stated R1 lived at the facility for 4 years and that they could not understand why R1 was expected to replace the carpet. Continuation on 9099-C. Unsubstantiated Relevant party stated that the facility eventually refunded R1’s estate the proper amount. LPA interviewed Administrator in December 2025, and she stated she did charge R1 for carpet replacement, but they were looking into it. Due to the information gathered, LPA finds allegation to be UNSUBSTANTIATED. LPA investigated allegation, “Staff do not respond to resident's call for assistance in a timely manner”. LPA interviewed relevant parties and staff and reviewed resident documentation. LPA interviewed relevant party in which she stated there were several times that R1 pushed their pendant for help, and it took from 28 minutes to 40 minutes for staff to respond. Relevant party stated R1 didn’t use their pendant much and only used it an emergency and staff were slow to respond. LPA interviewed 5 care staff in which they stated they usually respond within 5-10 minutes of when a pendant is pushed. At times if they are helping other residents, it may take longer. Of the 5 care staff interviewed, no one remembered a time that R1 was waiting for a long period of time for help. LPA interviewed administrator in which she stated there is a call button log, but it only stores information for the past 30 days. LPA was unable to review call lights pushed for R1 during their time at the facility. Due to the information gathered, LPA finds allegation to be UNSUBSTANTIATED. LPA investigated allegation, “Staff did not clean resident’s room”. LPA interviewed relevant parties and staff and reviewed resident documentation. LPA interviewed relevant party in which they stated R1’s room was lightly cleaned weekly by housekeeping, however of the 4 years R1 lived at the facility, the carpets were never cleaned, and a deep cleaning never occurred. Relevant party stated R1 was informed prior to move in that they would be receiving a carpet cleaning and deep cleaning annually. LPA reviewed R1’s admission agreement, and found that weekly housekeeping would be provided, however LPA did not observe anything about a deep cleaning and carpets being cleaned annually. LPA interviewed maintenance director in which staff provide weekly housekeeping which includes vacuuming, dusting, and bathroom cleaning. In addition, annually they provide deep cleaning which can include carpet cleaning and as needed cleaning. Maintenance Director provided LPA several dates in which spot carpet cleaning was provided but had no further documentation about annual deep cleanings. Due to the information provided, LPA finds allegation to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview was conducted.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 59-AS-20251212104918

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to complete the annual inspection. LPA met with Administrator Barbara Fleck during today's inspection. Currently there are 7 residents receiving hospice care. LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 6 resident rooms, medication rooms, staff area, bathrooms, kitchen, common living spaces, outdoor spaces, and activity areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the assisted living side of the facility and the memory care unit with a delayed egress. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete. Water temperature was measured at 112 degrees. LPA reviewed 14 resident files and 15 staff files. LPA reviewed 4 resident medications comparing with current physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated training completed and CPR and first aid certificates present. LPA observed a copy of current liability insurance. No deficiencies cited during today's inspection. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jan 29, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to complete a case management visit. LPA met with administrator Barbara Fleck during today's inspection. During today's visit, LPA arrived to gather further information on an incident report that was received. LPA reviewed resident documentation and interviewed administrator. In addition, LPA reviewed information on a concern from a resident. LPA interviewed administrator and resident and reviewed documentation. At this time no deficiencies have been cited. Exit interview completed and copy of report provided.the state’s words, verbatim · CDSS document, Dec 2, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. During today's inspection LPA met with Administrator/Executive Director Barbara Fleck. LPA arrived to obtain further information regarding a resident concern. During today's inspection LPA interviewed Administrator and requested resident documents. In addition, LPA interviewed 2 residents in care. No deficiencies cited during today's in inspection. Exit interview conducted and copy of report was provided.the state’s words, verbatim · CDSS document, Oct 16, 2025

Allegation investigated: Staff verbally abusive towards resident Staff not ensuring resident's safety with wheelchair

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Administrator Barbara Fleck to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unsubstantiated Staff verbally abusive towards resident Interviews conducted with staff members S1, S2, S3, S4 and S5 indicated that staff members haven’t been heard being verbally abusive towards residents in care. Each staff member indicated that there are times where they have to elevate their voices due to residents not being able to hear (due to hearing loss) or understand the staff correctly. Interviews with residents R3, R4, R5 and R6 indicated that staff are helpful at all times and have not heard any staff verbally abusing residents in care. Staff not ensuring resident's safety with wheelchair Interviews conducted with staff members S1, S2, S3, S4 and S5 indicated that staff members are trained to lock the wheelchair while transferring a resident to or from their wheelchair. All staff interviewed indicated that some residents prefer to lock their own wheelchairs. Interviews with residents R3, R4, R5 and R6 indicated that staff assist with wheelchair transfers as needed but they lock their own wheelchair wheels. R3, R4, R5, and R6 did not have any complaints or concerns with staff assisting during transfers. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jul 1, 2025 · control 59-AS-20250523090115

Allegation investigated: Staff did not ensure resident's incontinence care needs were properly met Facility has insufficient staff to meet the care needs of residents in care

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Administrator Barbara Fleck to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unsubstantiated Staff did not ensure resident's incontinence care needs were properly met In review of records and interviews, care staff were ensuring that resident (R1) was being checked on or being changed every two (2) hours R1’s needs and service plan. According to R1’s assessment completed on December 12, 2024, staff were responsible to “assist with toileting according to schedule, need and requests”. Based on records reviewed and interviews, care staff ensured that R1’s incontinence care needs were appropriately met. Facility has insufficient staff to meet the care needs of residents in care- Interviews indicate that there is sufficient staffing to meet the care needs of the residents. Staff are able to address resident needs in an efficient and timely manner. Observations indicate that staff are available to ensure that residents needs are being addressed either by seeing a need or the call button system. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents. Staff did not follow resident's physician orders Interviews with Executive Director (ED) and Health Services Director (HSD) indicated that the staff were following correct procedures for Resident (R1) care needs according the R1’s care needs assessment. Review of R1’s records indicated that R1 was receiving a re-assessment by HSD every six (6) months to ensure accuracy of R1’s care needs. In records reviewed, care staff and med-techs were following physician’s orders that were sent to facility. Staff mismanaged resident's medications Review of facility’s medication room indicated that medications were organized and free of clutter. In review of Medication Administration Record (MAR) for three (3) residents, medications are being dispensed and given according to physician’s orders on file. In review of Centrally Stored Medication Record (CSMR) for three (3) residents, all medications were documents according to physician’s orders on file. Med- techs document each time a resident takes a medication, refused or not given for a specific reason through the Electronic Medication Chart. Staff did not issue refund to resident's authorized representative Interview with Executive Director (ED) indicated that a refund was sent although Resident (R1)’s responsible party did not provide a thirty (30) day notice to facility per the admission agreement signed by R1’s Power of Attorney (POA). R1’s responsible party did not provide anything in writing, only verbally, to facility stating R1 was moving out of the facility on 03/17/2025. Interviews indicated that R1’s responsible party came to facility on 03/17/2025 and started packing R1’s belongings to move R1 from facility with no notice to staff or the ED. In review of Resident R1’s admission agreement, agreement states that “if you move out without a thirty (30) day notice, you will be responsible for the amount of your monthly fee through the date you move plus one full month’s rent”. The admission agreement was signed by R1’s power of attorney acknowledging the terms and agreements prior to moving in the facility. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.the state’s words, verbatim · CDSS document, May 15, 2025 · control 59-AS-20250430085814

Allegation investigated: Staff did not keep the facility clean, sanitary and free from odor Staff did not report a change in resident's condition

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Executive Director to deliver findings for the above complaint allegations. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: ***Report continued on 9099-C*** Substantiated Staff did not keep the facility clean, sanitary and free from odor The department investigated allegation, “Staff did not keep the facility clean, sanitary, and free from odor. LPA interviewed staff, relevant parties, witnesses, and reviewed facility records. Interviews indicated that R1’s room had strong smells of urine. LPA interviewed care staff in which they stated resident was incontinent and would have accidents. Care staff stated they would clean resident and residents’ room and give R1 showers when needed. LPA interviewed R1’s family in which they stated they observed R1’s bathroom being unclean and R1’s bathroom having a smell of urine to it. LPA interviewed a witness, and they stated resident’s room smelled strongly of urine and was unclean. LPA observed on outside agency documentation that resident bed was unclean and window had to be opened due to the smell. Based on interviews conducted and observations, staff did not ensure the facility was kept sanitary and odor free. Staff did not report a change in resident's condition. The department investigated allegation, “Staff did not report a change in resident’s condition”. LPA interviewed staff, relevant parties, witnesses and reviewed facility, and hospice records. Interviews indicated R1 lost 30 pounds between the month of March 2024 to June 2024. Facility did not report weight loss to R1’s primary care physician or responsible party. LPA interviewed facility staff in which they stated they did not observe R1 having wight loss during their stay at the facility. Interviews with the memory care director indicated staff weigh residents monthly and will report changes to doctor and responsible party if necessary. Memory care director stated there was nothing significant to report to family. LPA reviewed hospice documents in which it states R1 weighed 206 pounds in January 2024 and her last recorded weight in June 2024 was 176 pounds. R1 lost 30 pounds in 6 months. Based on information obtained, R1 was found to have lost 30 pounds in 6 months and facility did not report the change to R1’s primary care physician or R1’s responsible party. Based on the information obtained for the allegations above, the allegations are SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted with Executive Director and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Apr 2, 2025 · control 59-AS-20240823174553

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 30, 2025

87303(a) Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This poses a potential health and safety risk to the residents in care. This requirement is not met as evidenced by: Based on interviews conducted, staff did not ensure that R1’s room was free of odor and kept clean and sanitary.the state’s words, verbatim · CDSS document, Apr 2, 2025

Plan of correction: Facility will conduct a staff training and submit training information/proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Apr 30, 2025

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning… When changes such as unusual weight gains or losses… are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person... This poses a potential health and safety risk to the residents in care. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, facility did not report changes in R1’s weight to the responsible party or medical professional.the state’s words, verbatim · CDSS document, Apr 2, 2025

Plan of correction: Facility will conduct a staff training and submit training information/proof to LPA by POC due date.

Allegation investigated: Resident sustained frequent falls and bruises while in care at the facility.

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Administrator Barbara Fleck to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unsubstantiated LPA interviewed Staff members S1, S2 and Administrator Barbara Fleck. During LPA’s interview with S2, they stated that resident R1 currently resides in memory care. Care staff check on R1 as resident is a fall risk per fall risk assessment completed by facility on January 19,2025. Interviews indicated R1 often attempts to walk around without assistance. Interview with S1 indicated that R1 had a recent fall risk assessment and needs and services plan update to accommodate R1's new needs. Interviews with both S1 and S2 indicated that R1 is encouraged to remain in common areas during the day where R1 can be closely monitored by staff members. Interview with Administrator Barbara Fleck indicated that she is working with R1’s family to create a care plan to address falls and ensure R1’s safety at the facility. LPA reviewed R1’s physician’s report, individualized service plan, fall risk evaluations dated October 9, 2024, and January 19, 2025, and R1’s assessment for functional capabilities. Facility has appropriately assessed R1 for fall risks and has put measures in place in order to help prevent falls. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Mar 5, 2025 · control 59-AS-20250204144802

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA conducted an inspection of the care facility to ensure compliance with Title 22 regulations. LPA observed three (3) apartments in Assisted Living, three (3) apartments in Memory Care, two (2) common area bathrooms, kitchen and food storage rooms, medication room, salon, and common areas. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 116.7 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care facility has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed the perimeter of the care home to be free of clutter and debris. LPA ensured that delayed egress in Memory Care was operational. Smoke detectors and carbon monoxide detectors are hard wired in the care facility and control panel shows all systems are in working condition. Fire extinguishers are maintained and ready for emergency use. LPA reviewed six (6) resident files and four (4) staff files during visit. First aid kit is maintained and ready for emergency use. LPA checked medication storage and found medication to be locked away and inaccessible to the residents. Facility has a current copy of certificate of liability insurance and LPA requested a copy. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit was interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Feb 12, 2025

Allegation investigated: Staff member handled resident in a rough manner

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings into allegation listed above. LPA met with Health Services Director Lisa Velasco during today's inspection. LPA investigated the allegation, "Staff member handled resident in a rough manner". LPA conducted interviews with staff and residents. LPA interviewed resident in which they stated caregiver grabbed their wheelchair and moved them in a rough manner. Resident reported their foot was hurt in the process. LPA interviewed staff involved in which they stated they never touched the resident. LPA interviewed a witness in which they stated they did not observe staff handle resident in a rough manner. Due to the conflicting information gathered, LPA finds allegation to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview was conducted and copy of report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 13, 2024 · control 59-AS-20240918134818

Allegation investigated: Facility fail to ensure care to resident. Staff overly medicated resident. Staff is not qualified to conduct registered nurses' tasks.

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint investigation findings. LPA met with Administrator Haley Thomas during today’s inspection. LPA investigated the allegation, “Facility failed to ensure care to resident.” LPA interviewed 13 caregivers in which they stated they help provide care to R1. In addition, R1 has a private caregiver to ensure care is being provided. LPA interviewed family member in which they stated R1 receives care from the staff at the facility and a private caregiver. Family member had no concerns with the care being provided. LPA interviewed 5 residents in care in which they stated they receive care and help when needed and had no further concerns. Continuation 9099-C. Unfounded Due to the information gathered, LPA finds allegation to be UNFOUNDED. LPA investigated the allegation, “Staff overly medicated resident”. LPA interviewed staff, and reviewed resident documentation. LPA interviewed 13 staff members, all staff stated there are no concerns with resident’s being overly medicated. Staff reported they follow doctor orders and only provide medications as prescribed. LPA reviewed R1’s medication orders, physician’s report, and facility MAR. Documentation shows facility is providing R1 with medications as prescribed by the doctor. LPA interviewed a family member in which they stated R1 receives their medication as prescribed. Due to the information gathered. LPA finds allegation to be UNFOUNDED. LPA investigated allegation, “Staff is not qualified to conduct registered nurses tasks.” LPA interviewed staff and reviewed resident documentation. Relevant party stated S1 reinserted R1’s catheter once it became dislodged. S1 is not a registered nurse or other health care professional. LPA reviewed R1’s documentation, in which it stated R1 did dislodge catheter and it was reported to the hospice agency who came out to treat R1. LPA interviewed 12 staff members in which they stated they have not observed S1 perform registered nurses tasks before. LPA interviewed family member in which it was reported to them that S1 did not reinsert residents catheter. Family member stated it could have been a different caregiver. LPA attempted to interview a potential witness but was unable to get a hold of them. Due to the information gathered LPA finds allegation to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted.the state’s words, verbatim · CDSS document, Aug 13, 2024 · control 59-AS-20240612114234

Allegation investigated: Staff member did not treat residents with dignity and respect.

Licensing Program Analyst (LPA) Bethany Mirlohi and Graham Gunby arrived unannounced to deliver complaint investigation findings. LPA met with administrator Haley Thomas during today’s inspection. LPA investigated allegation, “Staff member did not treat residents with dignity and respect”. LPA conducted interviews with staff and residents and reviewed documentation. LPA interviewed staff, in which 11 of the 13 staff stated they have not observed S1 yell or speak inappropriately to clients in care. 1 caregiver stated they have witnessed S1 speak down to residents in care. LPA interviewed 1 witness in which they stated they have witnessed S1 speak to families inappropriately. LPA interviewed 1 family member in which they stated S1 was rude to them on several occasions. Continuation on 9099-C. Unsubstantiated LPA interviewed 5 residents in care in which 4 of 5 clients stated S1 has never yelled at them and they have never had an issue with S1 being unkind or inappropriate. Due to information gathered LPA finds allegation to UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview conducted.the state’s words, verbatim · CDSS document, Aug 13, 2024 · control 59-AS-20240708083743

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with Administrator Haley Thomas during today's inspection. LPA arrived to discuss an incident report received from the facility. LPA interviewed administrator concerning incident and obtained paperwork. It appears facility followed proper protocol and regulation on incident that occurred. No deficiencies cited during today's inspection. Exit interview conducted.the state’s words, verbatim · CDSS document, May 15, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue annual inspection. LPA met with Haley Thomas during today's inspection. LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 6 resident rooms, medication room, staff area, bathrooms, kitchen, common living spaces, outdoor spaces, and activity areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the assisted living side of the facility and the memory care unit with an approved delayed egress. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete. Hot water was measured at 118 degrees. LPA reviewed 4 resident medications comparing with current physician orders. LPA interviewed residents and staff. Deficiencies are cited on 809-D. Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 25, 2024

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct the annual inspection. LPA met with Administrator Haley Thomas during inspection. Currently there are 83 residents of which 6 residents are receiving hospice care. LPA reviewed 10 resident files and 10 staff files. Staff records reviewed indicated training completed. LPA observed a copy of current liability insurance. LPA observed not all care staff had updated CPR and first aid certificates. Due to time restraints LPA will return on a later date to conclude annual inspection. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jan 24, 2024