Oakwood Meadows Assisted Living

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Kayla Peria, Resident Care Coordinator (RCC) and Karen Padilla, Director of Nursing (DON), stating the reason for today's inspection. The following (3) incident reports were discussed. Resident (R1) went to the emergency room on September 12, 2026 for having a rash on both arms and legs, which they stated was itchy. (R1) returned the same day with a diagnosis of an allergic reaction, likely due to the antibiotic, Clindamycyn, prescribed on September 9, 2026, for cellulitis on both legs. (R1) returned with (2) new medications- Cetirizine 10 mg and Doxycycline 100mg, twice daily and will be referred for home health services. Staff will assist with elevating (R1's) legs to reduce swelling. (R1) is doing better currently. Resident (R2) wandered into resident (R3's) room on September 14, 2026 (7:00 am), as staff were getting residents ready for breakfast. (R3) scratched (R2) on their face after entering their room and staff immediately responded to screams heard from (R2's) room. Staff applied first aid to (R2's) face which has almost entirely healed. No other injuries were noted. Staff will continue to monitor (R2) and (R3) as well as conduct hourly checks for all residents in the Memory Care Unit (MCU) during the pm and NOC shifts. Staff will also continue to regularly redirect (R2) back to the common area when walking through the MCU. Resident (R4) was sent to the emergency room on September 12, 2026 (1:00 pm) after showing a change in baseline that included refusal of liquid, food and medications. (R4) regularly required assistance with feeding so staff was assisting with meals, drinks and snacks throughout each day. (R4) has been on/off hospice for over 2 years and was last placed on hospice on September 18, 2024 with an admitting diagnosis of a stroke. (R4) has had limited verbal ability but was able to express her needs to staff. (R4) had lower and upper extremity contractures prior to being sent out on September 12, 2026. *report continued on 809C-1.. 809C-1.. The RCC stated she was the Med-Tech on shift on September 12, 2026 (am) and (R4) was spitting out food and biting on the spoon but had no coughing. (R4) was offered Ensure protein drink but declined. The DON and RCC confirmed (R4) only takes a Calcium supplement and a Multi- vitamin. Both managers also stated that (R4) would regularly drool, when sitting up, prior to being sent out. The facility was advised by (R4's) responsible person that (R4) suffered a severe stroke on their left side which affected their ability to swallow. (R4) returned to the community on September 14, 2026 under hospice care, and hospice medications have been started. LPA observed the discharge paperwork and only a diagnosis of a stroke (CVA) was noted and no changes in the diet were made. Both the RCC and DON confirmed that Med-Tech staff have had recent training on signs/symptoms of strokes. A training on this topic will be scheduled to be conducted for caregivers within the next week. It appears the facility took appropriate and timely action in accessing each resident discussed in the report , and in responding with the appropriate staff intervention, including sending the resident out for further medical evaluation. There are no deficiencies issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 18, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Kayla Peria, Resident Care Coordinator (RCC). LPA stated the reason for today's inspection. LPA was advised the Administrator and Director of Nursing were currently out of the building. LPA and RCC discussed the following incident reports recently submitted to the Department. Resident (R1) had a witnessed fall on September 3, 2026 (1:20 am) after falling forward from a bench they were seated on. (R1) hit their head on the floor which resulted in bleeding. Care staff who observed the incident immediately reported it to the Med-Tech on duty, who assessed the resident and provided first aid care. (R1) was promptly sent out for further medical evaluation and returned to the community later that day (9:30 am) with a diagnosis of a fall with a hematoma on the forehead. No medication changes were made. (R1) was admitted to hospice the following day due to showing a decline, prior to the fall , related to eating less and having screaming behaviors. Hospice and Med-Tech staff have continued to provide first aid. LPA observed (R1) to be sitting in the common area of Memory Care during today's inspection, and the hematoma and related bruising on their face to be healing. Staff will continue to monitor (R1) for any needs/changes. Resident (R2) and resident (R3) had an altercation on September 8, 2026 (4:35 pm). Both residents have a diagnosis of Dementia. (R3) was fiddling with (R2's) items while (R2) was watching television. (R2) became upset and attempted to hit (R3) which resulted in (R3) knocking over (R2's) drinks- both residents then began hitting one another. (3) staff immediately intervened and separated the residents. (R2) went to their room and (R3) finished dinner in the dining room. Both residents were evaluated for injuries and none were noted. The RCC stated this was an isolated incident and (R3) exhibits significantly less behaviors now than previously. There is also an In-House Psych Doctor who visits every other week, or as needed, to evaluate residents with sundowning behaviors. LPA observed (R3) resting in their wheelchair during today's inspection. *report cont on 809C-1.. 809C-1.. Resident (R4) and resident (R5) were involved in an unwitnessed altercation on September 5, 2026. Staff immediately responded upon hearing screaming coming from (R4/R5's) shared room. (R5) stated to staff that (R4) kicked them in their leg, and (R4) stated that (R5) hit them and tried to push them out of their wheelchair. Staff immediately contacted the Director of Nursing and then separated the residents, calming them down. Both residents have a diagnosis of Dementia . (R4) was observed to be off baseline following the incident and was sent out for further medical attention. No injuries were noted on (R5). (R4) returned to the community the following morning (2:25 am) with a diagnosis of a Urinary Tract Infection (UTI) and started a (7) day antibiotic course. The RCC stated (R4) is prone to getting UTI's. Staff have continued to provide extra monitoring both residents and will do so for another (5) days. LPA spoke with (R5) who did not recall the altercation with (R4); however, mentioned that (R4) will "say scary things" in their sleep. The RCC agreed to follow up with the In-House physician for possible medications. The facility timely submitted an incident report and SOC341 to the Department following each incident. The SOC341 was also provided to the Ombudman's office. LPA toured the Memory Care Unit and common areas of the Assisted Living Unit during today's inspection. LPA observed many staff and residents to be engaged in various activities in both units. LPA observed the temperature just outside the door to Memory Care to be slightly higher- The RCC called Maintenance to address it immediately. LPA did not observe any doors to be blocked, any health or safety risks, or personal rights violations to residents in care. There are no deficiencies issued in this report. Exit interview with the Resident Care Coordinator RCC). Copy of report provided.the state’s words, verbatim · CDSS document, Sep 10, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection and met with Karen Padilla, Director of Nursing (DON), Kayla Peria, Resident Care Coordinator (RCC), and Danny Torgersen, Administrator. LPA stated the reason for the inspection. The facility is licensed for (78) non-ambulatory, or bedridden residents, and has a hospice waiver for (30) residents. Currently, there are (13) residents on hospice. There is an Assisted Living Unit (ALU) and Memory Care Unit (MCU). LPA, the DON and RCC toured the interior and exterior of the ALU and MCU, including the dining rooms, activity areas and enclosed patios. (5) rooms were inspected in ALU and (3) rooms in MCU. Hot water temperature was taken in (5) resident rooms total and measured 108*F - 117*F. The main kitchen was toured. There is sufficient 2+ day perishable, including fresh produce, and 7+ day non-perishable supply of food. There is a weekly menu, and each resident's dietary needs are posted in the kitchen. There is a monthly activities calendar in each living area. In all areas toured, there were no health and safety concerns, and the facility was observed to be clean, in good repair and odor free. The fire extinguishers were last serviced 11/12/2025. All required postings are visible in the common areas. Inside temperature measured 75*F. Vehicle service records reflect regular maintenance, and registration/insurance is current. Monthly Resident Council meeting notes were reviewed as well as weekly water/room temperature checks for residents. There are outside enclosed patios with tables/seating/umbrellas. There will be an outside sensory walking path for all residents in the upcoming months. (6) resident and (6) staff files were reviewed. Files are organized and contain current documentation. Resident physician's reports and care plans are current, within the last (12) months. *cont on 809C.. 809C-1...LPA reviewed medications for (1) resident in ALU. Medications are being administered per orders and documentation is electronically maintained. A pharmacy audit is competed every quarter to ensure compliance, and there were no errors discovered at the last audit. All staff is cleared/associated. Staff is completing required training through an approved vendor, including First Aid/CPR, and monthly In-Service training is done on a variety of topics. Staff also participate in monthly fire/emergency drills. LPA requested an updated copy of liability insurance, LIC308 and LIC500 be provided to the Department by August 28, 2026. There were no deficiencies observed. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 20, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Administrator, Danny Torgersen, Director of Nursing (DON), Karen Padilla, and Kayla Peria, Care Coordinator Assistant. LPA stated the primary reason for the inspection was to follow up on the recent GI outbreak at the community. LPA confirmed that the last resident to show signs/symptoms was on June 28, 2026, and resident (R6) no longer has any symptoms. LPA and the DON discussed the documentation submitted to the department on June 22, 2026, when the initial cases were reported. The DON confirmed an incident report was submitted for each resident that was sent out to the hospital for medical treatment. All residents have returned and fully recovered. Additionally, (2) staff members presented with signs/symptoms on June 22, 2026, and have also fully recovered. After the initial cases appeared, the facility contacted local public health and followed their infection control policy, including placing signage up at entrance doors, wearing PPE, and following their environmental cleaning protocols. During today's inspection, the DON provided LPA with documentation from a county public health nurse clearing the facility from the outbreak. LPA and the DON discussed (5) residents who passed over recent months who were not under hospice care. LPA obtained a copy of the county death certificate for (3) residents, (R1, R2 and R3), and confirmed that the facility will continue to try to contact (R4's) family member for a copy of the county death certificate. The DON stated that (R5's) conservator will provide a copy when available. There are no deficiencies issued in this report. Exit interview with the DON. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 2, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Administrator, Danny Torgersen and Director of Nursing (DON), Karen Padilla. LPA stated the reason for the inspection was to discuss an incident report submitted to the Department on June 3, 2026, for resident (R1). There are currently (75) residents, (13) of whom are under hospice care. LPA discussed the incident where (R1) had an unwitnessed fall in their room on June 1, 2026. The DON stated she observed (R1) after the fall and their shoes nearby, and explained it appeared (R1) tripped on their shoes, which were open-backed. (R1) was sent to the emergency room following the fall and had surgery for a right hip femoral neck fracture. (R1) was also diagnosed with a Urinary Tract Infection (UTI), will be starting Physical Therapy, and may go to a skilled nursing rehabilitation facility for recovery and pain management. The DON stated (R1) moved in and was able to walk without a walker/cane. The Physician's Report (February 2026) notes (R1) is ambulatory. The Pre-Appraisal (May 2026) notes (R1) is ambulatory with a walker, does not have a visual impairment, and would regularly ambulate fine without a walker. Also discussed were updates on several residents, including those who recently had a UTI, changes in medications, or showed agitation. LPA asked that managers ensure staff are providing regular hydration to residents and offer water and cranberry juice. The DON stated staff regularly offer liquids and Popsicles to residents and will continue doing so. LPA suggested a staff refresher training be conducted to ensure residents remain hydrated during these upcoming summer months. This training was previously for today. It appears the facility sent (R1) out timely for medical intervention after their fall. There are no deficiencies issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 4, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Administrator, Danny Torgersen; Director of Nursing, Karen Padilla; and Kayla Peria, Resident Care Coordinator (RCC). LPA stated the reason for today's inspection. There are currently (76) residents, (10) of whom are under hospice care. LPA and facility managers discussed several recent incident/death reports that were faxed over the last few weeks that were not received due to technical issues with the Department's fax line. LPA was provided with a scanned copy of all reports during today's inspection. Reports relate to residents (R1 to R6, as listed on Confidential Names List). Specifics were discussed such as any residents who remain hospitalized. Also discussed was a resident (R1) who recently moved out. LPA was provided with documentation related to the move out. (R1) was sent to the hospital on April 30, 2026, as (R1) requested due to a possible Urinary Tract Infection (UTI) and was diagnosed with a UTI. LPA and RCC conducted a health and safety inspection throughout both Assisted Living and Memory Care Units. In all areas toured. LPA observed signs posted on emergency exits reminding staff not to block the exits. LPA observed new flooring throughout the facility and was advised safety chairs were purchased for each resident room in the community. LPA did not observe any health and safety risk or personal rights violation. There are no deficiencies issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, May 8, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Kayla Peria, Resident Care Coordinator (RCC). Administrator, Danny Torgersen, arrived at 2:45 pm. LPA stated the reason for the inspection was to follow up on several incident reports submitted to the Department, as follows: Resident (R1) had an unwitnessed fall on 4/1/2026. (R1) denied pain but showed signs of confusion. A non-emergency medical transport company was contacted, arrived to do an assessment and found (R1) to be alert and oriented and refused transport to the Emergency Room. On 4/7/2026 (1:30 pm), (R1) had a witnessed fall while using their walker in the front reception area. (R1) hit their head against the wall and sustained a bruise. (R1) was sent out to the Emergency Room and admitted with a diagnosis of a contained brain bleed. (R1) remained hospitalized and will be returning to the community today, as they are stable. The facility was informed that the medication, Metropolol 25 mg was not administered during part of the hospitalization as it seemed to cause (R1) to be dizzy, perhaps contributing to the falls. The RCC stated that (R1) has used a walker for some time and they believe (R1) is declining overall. The care plan notes (R1) has a history of falls, staff will provide assistance in the case of a fall and there is a fall prevention program in place. Home Health referral is pending for (R1). Resident (R2) had an unwitnessed fall on 4/2/26 (8:35 pm) and sustained some bleeding from their head. (R2) indicated they were trying to get up to get something to drink in their room. (R2) was sent out for further medical assessment and returned the same day with a referral for Home Health and no medication changes. Facility staff have been monitoring (R2) closely, sitting in the nearby hallway and will continue to provide first aid treatment for a small skin tear sustained. *cont on 809C-1.. 809C-1... Resident (R3) and resident (R4) are roommates in Memory Care. On 4/5/2026 (4:10 am), (R4) alleged that (R3) hit (R4) in their head after accusing (R4) of taking their jacket. Staff promptly responded and observed (R4) to be backing out of their room. (R4) was sent out for medical evaluation and returned the same day with a diagnosis of an unknown small bump. The RCC stated labs were done for (R4) and (R4) is back to baseline. The RCC stated staff in Memory Care will conduct "hourly checks" from 7:00 pm- 6:00 am and document on a chart if the resident was awake or sleeping. The RCC confirmed there are (2) caregivers working during the NOC shift as well as (1) Med-Tech. The RCC indicated that (R3) denied hitting (R4), and has had not previously shown aggression towards (R4) or any other resident. The facility timely submitted an incident report and SOC341 for the above incident, as well as incident reports for the other incidents referenced in this report. It appears the facility took appropriate action following each incident in assessing the resident. There are no deficiencies issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 10, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Danny Torgersen, Administrator and Kayla Peria, Director of Care and Admissions. LPA stated the reason for today's inspection was to follow up on an email notification received from a related state agency following an inspection conducted on March 16, 2026. The email reads in part, as follows: During the inspection, two emergency fire exits were found to be obstructed. The first exit, situated in the Memory Care (MC) area leading to the MC courtyard, was blocked by chairs and a rolling cart. The second exit, located in the MC courtyard and providing access to the front of the facility, was obstructed by an outdoor glass table. Today, LPA and managers toured the Memory Care Unit and observed all emergency exits to be free of any blockages; however, there was a rolling cart near the interior exit door. The managers explained that on March 16, 2026, a resident bench and rolling cart were placed in front of the interior exit door, and one of the glass patio tables had been moved and was blocking the outside emergency exit door. Managers stated that staff know not to block doors and residents may have moved furniture and were not sure how the furniture was moved prior to the inspection on March 16, 2026 (9:45 am), but a lot of furniture was moved due to new flooring being recently installed. The Director of Maintenance stated staff may have temporarily blocked the interior emergency exit door, if a resident was trying to leave from the secured memory care unit. All managers stated that training is conducted regularly to ensure staff are aware that an emergency exit can never be blocked and the Fire Marshall conducts an annual inspection. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is issued on the 809D page. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 25, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Mar 26, 2026

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on documentation reviewed and interviews conducted, the Licensee did not ensure that all emergency exit doors remained free of any blockages on March 16, 2026 (9:45 am approx) when an inspection was conducted by a related agency, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 25, 2026

Plan of correction: Licensee/Administrator agree to conduct a refresher training with all staff to ensure their understanding that emergency exit doors, or other exit doors, cannot be blocked, at any time. Since 2024 or earlier, front desk staff has been touring and checking all exit doors for operation at the start of each shift and will continue to do so. Documentation of training conveyed during today's inspection- will be held on April 2, 2026 (Mandatory All Staff). Documentation to be submitted lby April 3, 2026.

Allegation investigated: Medication is being mishandled by staff. Staff is not communicating with other staff af shift change. Licensee retaliated against staff for speaking with state staff at the facility.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on October 23, 2025. LPA met with Director of Nursing (DON), Karen Padilla and stated the reason for the inspection. During the investigation, LPA interviewed the Administrator, the DON, the Human Resources Director, the Care and Admissions Director, multiple faciity staff, (2) residents and (2) hospice personnel. LPA reviewed documentation including Nurse Audits of Medication (July 2025), Physician's Orders, Staff Handbook with facility policies, staff Termination Letter, written staff statements, and other documentation. The results of the investigation are as follows: *cont on 9099C-1.. Substantiated 9099C-1.. Allegation: Medication is being mishandled by staff. The allegation states than a Med Tech on the "am" shift has been observed to walk away from the medication cart, without securing it and to leave medications for residents in their rooms without ensuring they are immediately taken. Additionally, loose medications have been found in resident wheelchairs, in beds and on the floor. One Med-Tech explained that the procedure for administering resident medication is to "check the resident's chart, look at the board in the Med Room and check the MAR (Medication Administration Record) if there are any antibiotics to be administered. This Med-Tech explained she looks at each resident's names before administering the meds and confirmed residents "will refuse sometimes and we will try 3-4 times", confirming the meds stay in the cup and she will put the cup back in the medication cart if the resident refuses. The Med-Tech confirmed that staff are not trained to leave medications with residents, asserting, "No, we can't leave medications with residents". A second Med-Tech (pm) stated she "makes sure meds are taken by the resident, residents usually takes meds willingly", and pre-poured meds are in "cups that are in a little case that is locked". A caregiver was asked if Med-Techs will leave the medication cup with pills in the resident's room and go to the next resident's room and replied, "Yes, they leave the whole cart and laptop open"- you can see resident's profile and medications they take. The staff added, "sometimes the Med-Tech will ask a non-Med-Tech, or a caregiver to walk the medications to a resident's room, and this usually occurs on the "am" shift. Another caregiver stated she found a paper cup with a red pill in it in Hallway A and gave it to the DON on October 16, 2025. LPA and their manager spoke to (2) residents in the Assisted Living Unit on January 30, 2026. The residents were asked if Med-Techs leave the medications and then proceed to the next resident's room, or if the Med-Tech waits for them to take the medications. One resident responded "sometimes they leave the medications and go". A second resident stated "they leave the medications- they leave them for me at 8:00 am" and then "around 8:30/9:00 am, I take the medications myself". LPA reviewed the Physician's Orders for these two residents. One resident takes the following scheduled medications at 8:00 am: Buspirone 10mg, Metformin 500 mg, Fluticasone Prop 50 mcg nasal spray The second resident takes the following scheduled medications at 8:00 am: Aripiprazaole 5 mg, Oxybutynin Chloride 5 mg and Phenazopyridine HCL 40 mcg. *cont on 9099C-2.. 9099C-2..LPA reviewed a Nurse Audit for Assisted Living and Memory Care that were completed in July 2025 to evaluate areas of medication storage and systems. Scores for Memory Care ranged from 96%-100% accuracy in (6) of (7) areas, while controlled medications received an 83% accuracy score. For Assisted Living, the same areas were evaluated and given scores from 84% to 94%, with pharmacy processes scoring 100%, and diabetic supplies scoring 67%. Medication carts (2) were reviewed and recommendations were made to ensure all OTC medication has the resident's name on it as room assignments can change, and all House Supply OTC, which will be PRN medications only effective January 2026, be marked as House Supply and are properly logged with start dates. Another observation made during the audit was that staff were occasionally pre-signing before the change of shift occurred, when staff should only be signing once the count has been completed, including when working a double shift. Based on information obtained, the portion of the allegation about staff leaving medications for residents in their rooms without ensuring they are immediately taken is found to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Staff is not communicating with other staff at shift change. The allegation states that on/around September 2025 and October 2025, the facility did not have cross over meetings for caregiver staff to attend at shift change to receive resident status updates, and staff communication was very poor. One caregiver staff stated in October, 2025, that there is "no communication at cross over meetings", and she doesn't know which residents are on hospice or home health, or if there have been any concerns/changes the prior shift has to report. A second staff stated in January 2026, "Yes, generally we have cross over meetings" and explained "we didn't have shift meetings at that time", referring to on/around October 2025. A third staff stated in January 2026, "At that time, (October (2025), we did not have them", explaining that staff leaving their shift would just spend (5) minutes talking to the staff arriving, and commented, "the facility needs more structure", and commented, "Just now, starting last month, we are having meetings at shift change". A Med-Tech in January 2026 indicated caregivers will meet outside the common area to discuss if there are any changes in the residents. *cont on 9099C-3.. 9099C-3.. The HR Director was asked about shift change meetings in January 2026 and explained, "Caregivers on the "am" shift fill out a form and communicate- the caregivers give it to a Med-Tech "pm" staff- they talk in the hallways or look at the form", and stated there are stand-up meetings at 9:30 am on days we have events or the day before. The DON stated in February 2026 that a cross-over form was created prior to October 2025, but not all staff were not using it in October, but now they are. The DON stated that Med-Techs have always met with their caregivers at the start of the shift. Based on information obtained, the allegation is found to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Licensee retaliated against staff for speaking with state staff at the facility. The allegation states on October 14, 2025, an LPA came into the facility and staff (S1) was told to go and talk to her. (S1) states they told the interviewer everything she had observed and what was going on. When LPA asked to speak to additional staff, only one of three staff went to speak to the LPA. The next day, October 15, 2025, (S1’s) supervisor told them they wanted to speak to them about their conversation with the State yesterday and on October 16, 2025, they were called into a manager’s office and given a termination letter. LPA reviewed the “Notice of Termination” letter issued on October 16, 2025, that states (S1’s) employment is being terminated effective immediately, October 15, 2025. The letter references (2) specific dates and (3) incidents, as a basis to issue the termination letter. The first incident notes on October 9, 2025, (S1) was observed to show unprofessional behavior with a hospice nurse after being asked to leave the resident’s room, and (S1) became defiant with a Med-Tech. LPA was provided with (2) different hospice staff names and contacted each one. Both hospice staff confirmed that they did not recall this incident and stated they would never ask a caregiver to leave a resident’s room, as they often need their help. Interviews with several managers revealed that no manager had contacted the hospice staff to confirm the incident occurred but received this information from a staff that overheard the incident. *cont on 9099C-4.. 9099A-C-1.. Allegation: Vanity lights in resident rooms need to be replaced. The allegation states that work orders were submitted for vanity lights in resident rooms but are not not fixed timely. Room numbers were not provided. LPA and the Director of Nursing toured (5) resident rooms in the "A" Hall in Assisted Living Unit (ALU) on October 30, 2025. In one room, the DON had to push the reset button on the right side (A4) to get the vanity light to go on. In the (4) other nearby rooms, the vanity lights worked fine and there were no issues. The DON commented that both vanity lights were replaced a couple of days ago in one of the rooms (A9). LPA reviewed a copy of the Maintenance Request Worksheet- for jobs logged starting from September 30, 2025 through October 29, 2025. The maintenance log shows the following repairs were made related to bathroom lights in the ALU: 10/15/25- A4-B- Bathroom sink light out and on 10/29/25- ALU- room #D8- sink light out. The Maintenance Director was interviewed about the facility's Work Order processes and documentation. The Director indicated there is a work order binder at the front desk where maintenance requests are kept and confirmed that if the entry on the worksheet is "checked off, then it's been completed, which is usually within the next day". All of the jobs entered on the log were checked off except for (2) entered on October 28 and 29, 2025, which were for sink lights needing replacement in the facility's Memory Care Unit. Also discussed was how there is not a completion date/column listed currently on the form and how it would be a "best practice" to have a column to confirm when the job was completed. The Director agreed to add a column to the worksheet. Based on information obtained, the allegation was determined to be UNSUBSTANTIATED- A finding that the complaint 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. 9099C-4.. LPA interviewed the Med-Tech referenced in the letter who confirmed (S1) was asked to assist a resident who needed assistance with having their top changed after breakfast, and (S1) stated she would do so once she finished another task. The Med-Tech stated this discussion happened between 7:30 am-9:00 am and indicated she could not recall an incident involving (S1) and a hospice nurse on that day. The second incident states on October 15, 2025, multiple staff members observed (S1) to show inappropriate behaviors with resident (R1) in the hallway while trying to assist (R1) into a wheelchair. LPA was provided with multiple written statements from staff who observed the specific incident. LPA interviewed each staff and confirmed that each written statement corroborated with what each staff stated they had observed and with what other staff had observed. (S1) expressed she was never asked to leave a resident’s room by a hospice nurse, including on October 9, 2025, and explained on October 16, 2025, she was trying to get (R1) to sit in their wheelchair due to recovering from a recent fall, and was never physically forceful with (R1), or any other resident. LPA was provided with a copy of a text message sent from a manager to (S1) on October 15, 2025 (7:13 am) that states, “We would like to have a conversation of what you reported to state yesterday”. (S1) responded back “Ok”. Since the manager could not be at the facility on October 15, 2025, (S1) did not meet with any managers until the morning of October 16, 2025, when the termination letter was issued. The Termination letter closes by saying “Because you are still within your 90- day introductory period, and due to the severity and repeated nature of these incidents, management has decided to proceed with immediate termination of employment”. The HR Manager stated that (S1) had received at least (2) write-ups and confirmed she was not able to initially, or later, locate the write-ups prior to termination, or any other documentation showing a manager had discussed concerns with (S1) about their job performance. (S1) stated she was told by a manager in the meeting on October 16, 2025, that there had been multiple complaints about her, but was never approached by managers to discuss any issues, and only signed paperwork when hired on August 27, 2025, and terminated on October 16, 2025. (S1) indicated that during the termination meeting, managers could not provide her with any documentation regarding complaints made against her, including for the incidents referenced in the Termination Letter on October 9, 2025, and October 15, 2025, or any documentation that a manager had discussed job performance concerns with her. *cont on 9099C-5.. 9099C-5.. Although the Termination Letter does not reference (S1) speaking with the state on October 14, 2025, (S1) stated that during the termination meeting, she was told by a manager to only provide limited information to state personnel, when asked. LPA interviewed several other staff who indicated they were also told by management, around October 15, 2025, to tell State employees that everything is fine with the residents, and there are no problems. Based on information obtained during the investigation, the allegation is found to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (3) citations are issued on the 9099-D page. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 20, 2026 · control 59-AS-20251023111820

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Feb 23, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on interviews conducted, the Licensee did not ensure that all Med-Tech staff follow medication administration protcols, including ensuring residents take their medications when given to them, which poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Feb 20, 2026

Plan of correction: Licensee/Administrator agree to conduct an inservice training with all Med-Techs (am/pm and NOC) to go over protocols for medication administration. Documentation of scheduled trainingt due by Monday, Feb 23, 2026. Dccumentation of completed training due by March 5, 2026-

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 6, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on staff interviews, the Licensee did not ensure that shift change meetings and communications were occurring daily between staff, on/around October 2025, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 20, 2026

Plan of correction: Licensee/Administrator have since implemented shift change meeting notes due to some staff having to leave 15 mins early - Med-Techs, other staff will cover. The DON agrees to provide notes showing what form/s are being used by staff to prepare for shift change. Due by 3/6/26.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.37 · Plan of correction due date: Mar 6, 2026

§1569.37 Whistle blowers; retaliation No licensee, or officer or employee of the licensee, shall discriminate or retaliate in any manner, including, but not limited to, eviction or threat of eviction, against any person receiving the services of the licensee’s residential care facility for the elderly, or against any employee of the licensee’s facility, on the basis, or for the reason that, the person or employee or any other person has initiated or participated in the filing of a complaint, grievance, or a request for inspection with the department pursuant to this chapter, or has initiated or participated in the filing of a complaint, grievance, or request for investigation with the appropriate local ombudsman, or with the state ombudsman recognized pursuant to Chapter 11 (commencing with Section 9700) of Division 8.5 of the Welfare and Institutions Code. This requirement is not met as evidenced by: Based on documentation reviewed and interviews conducted, the Licensee did not ensure that (S1) was not terminated, in part, due to speaking with the LPA, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 20, 2026

Plan of correction: Licensee/Administrator agree to implement a (30)-day performance review for any future new staff and concerns and corrective action will be documented. Staff can also express any concerns they may also at this time. Facility to provide a form to be used - due by 3/6/26.

Allegation investigated: Staff hit resident.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on November 13, 2025. LPA met with Director of Nursing (DON), Karen Padilla. During the investigation, LPA interviewed the Administrator, the DON, and multiple faciity staff in Memory Care. LPA reviewed documentation relating to resident (R1), an incident report submitted for the incident occuring on September 1, 2025 and documentation from the faciltiy's internal investigation. The results of the investigation are as follows: Resident (R1) moved to the Memory Care Unit in the facility, on May 30, 2025, with a primary diagnosis of Senile Dementia and a history of lung cancer. The LIC602 (10/30/2025) notes that (R1) has “Behavioral Expressions”, including disorientation, lack of hazard awareness and impulse control, expressions of frustrations and hallucinations. **cont on 9099C-1.. Substantiated 9099C-1.. (R1’s) care plan (7/16/2025) states staff will ensure (R1) has safe ambulation, provide occasional assistance, they use a walker due to unsteady gait, and notes that (R1) "displays behavioral expressions such as agitation, refusal of care and confusion" and "requires reminders and cueing". Allegation: Staff hit resident. The allegation states that staff, (S1), physically punched resident (R1), in the back of their head around the end of August or beginning of September, 2025, and then went after (R1) attempting to punch (R1) more, but another staff intervened so (S1) walked away. LPA reviewed (5) staff statements and other documentation from the facility's internal investigation. (4) of the statements were from caregivers who were present at the start of the "am" shift on September 1, 2025, when the incident with (R1) occurred, and (1) statement was from the Med-Tech who received a verbal report from one of the caregivers later that same day, around 1:50 pm. LPA interviewed each of these (5) staff and was provided with varying accounts of how the incident occurred from the (4) staff who were witnesses. Although all caregivers stated that they observed (R1) pulled (S1's) hair, one caregiver stated they heard (S1) call (R1) "crazy", just prior to (R1) pulling (S1's) hair. Another caregiver who is familiar with (R1) stated they have observed (R1) to become aggressive with other residents, but never with a staff. Additionally, the written statements from the (4) caregivers do not include details or corroborate the information provided to the LPA during the interviews. One caregiver stated they provided details to management about what they witnessed; however, their written statement did not reflect a detailed account of the incident, and was not signed. LPA reviewed a second witness statement that also was not signed by the caregiver. The Med-Tech confirmed that what was reported to them by one caregiver was documented and submitted to management following the incident. In the Med-Tech's statement, it's also noted that (S1) was told they need to make a report of what was witnessed, as well as the (2) other caregivers who did not report what they witnessed. The facility's internal investigation "determined that the resident abuse claim was inconclusive; however, concerns about professional conduct and proper intervention were substantiated". As part of a corrective action plan, (S1) was issued a Performance Improvement Plan (PIP) on September 6, 2025, requiring (S1) to complete "mandatory training in de-escalation techniques, dementia care and customer service standards" with the purpose to “provide corrective direction, training and support to ensure safe, professional and compassionate care practices”. *cont on 9099C-2.. 9099C-2.. As part of the corrective action plan, (R1) was also required to review the facility's policies on Behavioral Intervention and Resident Rights, and participate in weekly 1:1 check-ins with a manager to discuss progress every (30) days. LPA reviewed documentation showing (R1) was evaluated on Oct 13, 2025, Dec 16, 2025, and on Jan 19, 2026. The Ombudsman met with the Administrator and the DON initially on November 18, 2025 and was told an internal investigation was completed and there was no evidence found to substantiate the allegation of abuse. The Ombudsman returned to the facility on November 19, 2025 to inform facility managers that (S1) was involved in a similar incident, that was witnessed at an unrelated facility, on November 14, 2025. During the meeting on November 19, 2025, it was discussed that a Report of Suspected Dependent Adult/Elder Abuse (SOC341) should have submitted to the Long-Term Care Regional's Ombudsman's Office immediately following the reporting of the abuse. The facility submitted a completed incident report (LIC624) to the Department (CCLD) after this meeting. Charting notes for (R1) show on 9/1/25 (1:00 am) staff made an entry that (R1) was observed with an indentation and cut on their outer right side of temple and that (R1) did not fall, but bumped their head on the night stand next to the bed, and refused to be sent out. Interviews concluded that staff were aware and observed (R1) had sustained bruising to their eye during the prior/NOC shift. There were no notes entered by the Med-Tech for the altercation (R1) had with (S1) on 9/1/25 (around 6:15 am). The next notes were entered on 9/4/25 (1:52 pm) and 9/5/25 (1:16 pm) and state that resident’s eye bruises (black eye) are healing and going away, resident is not complaining of pain/discomfort, and staff will continue to monitor. Based on information obtained, the allegation is found to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (2) citations are issued on the 9099-D page. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 59-AS-20251113134057

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Feb 19, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that (R1) was not subjected to verbal and physical abuse by staff (S1), on September 1, 2025 (at approximately 6:15 am), which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 18, 2026

Plan of correction: Licensee/Administrator immediately completed an inservice with all staff on mandated reporting. (R1) completed (6) classes of de-escalation and appropriately dealing with behaviors related to Dementia. The DON will advise by tomorrow, 2/19/26,what additional training will be conducted.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Mar 4, 2026

87211 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 of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that the alleged incident reported to management, between (R1) and (S1) , on September 1, 2025, was timely reported to the Ombudsman's office and to CCLD,the state’s words, verbatim · CDSS document, Feb 18, 2026

Plan of correction: Licensee/Administrator agree to read Regulation 87211 and submit a statement of understanding. Additionally, an In-Service training will be conducted with staff to review Abuse reporting requirements as stated on the SOC341A- Ombudsman training if possible. The DON indicated (R1's) family was notified and didn't express any concerns.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada and Ombudsman, Byron Toliver, arrived unannounced to follow up on recent concerns and an incident report and meeting notes submitted to the Department regarding resident (R1). LPA and the Ombudsman met with Karen Padilla, Director of Nursing, and Kayla Peria, Director of Care and Admissions, and stated the reason for the inspection. The following was discussed: The facility managers stated that (R1's) room was never searched without their permission and that on one occasion, (R1) granted the facility and local law enforcement permission to do so, after the reason was explained. LPA reminded the facility cannot search a resident's room and property, due to the resident's personal rights; however, law enforcement can be contacted, if there are concerns in the future. The Department was provided with a copy of meeting notes for a meeting held on February 3, 2026 with (R1) and several facility managers. The notes state that the purpose of the meeting was to discuss recent incidents which violate the facility's House Rules, which (R1) acknowledged. (R1) stated they would be moving to another location and submitted this request in writing. (R1) moved from the facility the following day, February 4, 2026. (R1's) prior roommate, (R2), was interviewed during today's inspection. (R2) indicated that they have never observed the facility to search (R1's) belongings while rooming together. It appears the facility followed the proper protocols and acted appropriately in discussing their concerns timely with (R1). There are no citations issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Feb 5, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to follow up on several incident reports submitted to the Department. LPA met with Karen Padilla, Director of Nursing, and stated the reason for the inspection. The following incident reports (LIC624) were discussed: Resident (R1) fell out of their bed on 12/16/25 (3:20 am) and a Med-Tech was notified by resident's roommate. (R1) was found lying on the floor in a side-lying position and stated they fell asleep at the edge of the bed and fell. No bruises or injuries were noted when resident was assessed. The DON stated on 12/19/25 that the facility is discussing getting a recliner chair for (R1) to sleep in and will contact the physician for approval. Currently (R1) is hospitalized for a diagnosis that affects how the resident sleeps. Resident (R2) was offered a prohibited substance on 12/9/25 (6:30 pm) from (R3) who received it from resident (R4). (R2) was sent out for further medical care and evaluation after showing signs of distress. (R2) returned from the hospital on 12/10/25 (1:40 am) after labs were cleared. No new orders were given. (R4) is independent and able to leave the facility unassisted and returned with the prohibited substance. The DON stated local Sheriff came out and spoke to residents (R2 and R4) who were reminded of the facility's policies and understand they can be issued a (30)-day eviction notice if the policies are not followed. Resident (R5) became aggressive towards staff and residents on 11/15/25 (4:00 pm) and began picking up chairs and attempting to strike. Care staff promptly intervened and (R5) was redirected back to their room prior to be sent out for further medical evaluation. (R5) returned the same day with a diagnosis of a Urinary Tract Infection and began a 7-day antibiotic. The DON stated (R5) frequently has behavior and the family also agrees to send resident out for further medical evaluation. During the day (R5) has less behaviors and the current care plan addresses these sundowning behaviors. *cont on 809C-1.. 809C-1 Resident (R6) had an unwitnessed fall on 12/17/25 (6:35 pm) and found on the floor in the activity room. (R6) was immediately assessed by a Med-Tech and no injuries/bruising were noted, nor any complaints of pain/discomfort. (R6's) responsible person was notified and staff continued to monitor resident. The DON stated today she is a moderate fall risk and doesn't have peripheral vision on both sides, so increases the risk of falling. (R6) is a wanderer throughout the hallways in Memory Care. It appears the facility took appropriate action in each of the above incidents noted. There are no deficiencies issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Dec 19, 2025

Allegation investigated: Staff did not provide adequate meals to resident in care.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete a complaint investigation and deliver findings to a complaint received on July 11, 2025. LPA met with Director of Nursing (DON), Karen Padilla, and the Administrator, Danny Torgersen. During the investigation, LPA interviewed the administraotor, DON, multiple faciity staff, the lead culinary staff, resident (R1) and (2) of their family members, and several random residents while eating lunch in the dining room. LPA observed food being served to residents on the Assisted Living side during lunch on October 14, 2025 and reviewed meeting notes and observations made during and following a Care Conference held on January 17, 2025. Additional documentation was reviewed related to (R1) including, but not limited to, care plan and physician's report. The results of the investigation are as follows: **cont on 9099C-1... Substantiated 9099C-1...The physician's report notes ((R1) has a diagnosis of Dementia and has some anxiety and depression. The care plan indicates (R1) needs assistance with medications, needs a walker at all times, receives Home Health Services due to weakness of ambulation, and needs minimal assistance with toileting, transferring, dressing and is independent with grooming. Also noted is (R1) requires a Special Diet: Vegetarian. Allegation: Staff did not provide adequate meals to resident in care. The allegation states in early 2025, resident (R1) was not eating due to horrible food at the facility; (R1) is a vegetarian, and facility staff allegedly knew resident’s dietary care needs. On 7/11/25, the administrator stated (R1) was at his door every day after moving in, complaining about how they didn't like the food served. The DON confirmed (R1) is "vegetarian", the kitchen is aware, and (R1) gets salads daily, commenting (R1) "is very thin and has lost weight", and the lead chef has started making smoothies. (R1’s) family member/s stated they believed that (R1) lost weight and became ill due to lack of nutritious foods, and many of the residents stare at the food and do not eat it because staff do not provide special diet plates or food accommodations. (R1) stated in July 2025 they have been vegetarian for 5 years and the facility is serving her salads and other vegetarian foods and does not eat hamburgers or chicken. LPA reviewed notes from a Care Conference Summary, on 1/17/2025, provided by the administrator noting that (R1) is a vegetarian, has reportedly been served meat, and the family requested more fresh options, such as salads and fruit. Staff stated they are familiar with her preferences. Family willing to visit and encourage eating when intake declines. Immediately following this meeting, the family went to talk to (R1) in their room and observed kitchen staff had served (R1) lunch consisting of deep fried chicken strips, French fries, and a white biscuit. On September 4, 2025, LPA observed (R1) to be waiting for an alternative to be served for lunch while another resident at the same table had been served. The lead chef stated (R1) has not taken food from other residents lately and is eating their own food, and he purchased Beyond Beef products to give to (R1) since they are a vegetarian. The chef stated staff witnessed (R1) take a BBQ beef sandwich from another resident at the same table and take a bite. *cont on 9099C-2.. 9099C-2.. Also on September 4, 2025. LPA discussed these following food concerns, as noted in the Resident Council notes (Aug and July 2025), with the Lead Chef. The Lead Chef stated he regularly attends the meetings and has made changes following resident's complaints, as follows:: tough pork chops- substituted with pork loin and sliced for resident portions- more tender than the chops more French fries-residents want the oil/fried French fries- extra crispy- may consider purchasing a few air fryers. too much fish served and more fresh fruit instead of cups LPA observed two lunch options being served in the Assisted Living unit on October 14, 2025. LPA spoke to many residents, including to (R1) about how they liked lunch and received mixed results if the food was tasty. LPA observed many resident plates to not be finished and the food to be discarded. Many residents indicated they enjoyed the apple crisp dessert. LPA observed (R1) to be eating berries, other fruit cut in small pieces, and oatmeal with seeds brought in by their family member. LPA observed resident (R2) to be eating a grilled cheese sandwich, which was not one of the two options served (tacos with beans and pork with rice, asparagus). (R2) indicated they are vegetarian and staff ask her at every meal what she would like. Today's menu shows a main choice and an alternative choice. LPA observed the "Black Beans and Vegetable Fajitas" to consist of tortillas, whole black beans and corn, and sour creme and a small amount of sauteed onions/peppers. Many residents complained to LPA that there was no meat or chicken in the "tacos". LPA was told by residents and observed that the "Rosemary Roast Pork" ( with wild rice, pilar and asparagus) was difficult to cut and chew for residents. A third resident indicated he would like to see hash browns served with eggs and bacon for breakfast and has never seen omelettes prepared. LPA observed a fruit basket in the dining room with (3) apples and (1) orange and was told by a family member that residents need soft fruits such as bananas, kiwi, and berries to be served and to cut up fruit that is difficult for residents without teeth to bite. The DON stated the fruit bowl is full in the morning with a variety of foods. Based on this investigation, the allegation is substantiated- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. Exit interview. Copy of report provided. 9099A-C-1... Allegation: Staff did not shower resident in care. The allegation states in early 2025, resident (R1) was not showered. No other details provided. Staff interviews indicated that resident (R1) would regularly refuse showers and staff would have to try and convince (R1) to take a shower on their scheduled shower days, Wednesdays and Saturdays. The facility shower schedules reflects (R1) was scheduled to receive a shower on these days, and the care plans notes these days also and resident has a preference showers be given in the morning. Morning shower schedules were reviewed for June 2025. Staff signatures were documented on each Wednesday and Saturday of each week in June to show (R1) received a shower as scheduled. One staff who regularly assisted (R1) with showers stated (R1) also allowed staff to wash their hair. (R1) confirmed they receive a shower every 2-3 days and is able to do their own shower, and commented additional showers can be requested anytime and staff will give them. LPA reviewed conference meeting notes from January 17, 2025, which discussed that "staff explained efforts to adjust caregiver assignments and timing when residents are resistant. Showers offered twice weekly due to skin fragility, but clothes are changed daily. Family suggested firmer encouragement from staff". Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED A finding that the complaint 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. Copy of report provided. *9099A-C-1.. Documentation provided to the Department shows that a higher monthly amount was charged initially, in November 2023 and then the monthly rate was reduced effective March 1, 2024. The monthly rent amount was decreased on/around May 2024 when a new rate structure began and was increased effective January 1, 2025 and then again on April 1, 2025. The administrator stated and the Pet Agreement show that the facility never charged to allow (R1) to bring the cat to the facility when moving in. The document was signed on November 27, 2023 by both (R1's) responsible person and a facility manager that there was neither a monthly fee or a one-time fee charged to allow the cat to reside with (R1). Based on information obtained, LPA finds this allegation to be UNFOUNDED- LPA finds the 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. Allegation: Staff threatened resident in care. The allegation states (R1) had a cat and staff used to help with cleaning the litter box. On 7/2/2025, (R1’s) family member received a text from the Administrator stating that staff and residents are complaining of the cat’s smell and unsanitary conditions, and the Administrator threatened to evict the resident. The administrator explained how (R1) was "very anxious the first week (R1) moved in" and the family asked if they could bring (R1's) cat to help them. The administrator stated he told the family that the facility was "not accepting pets at this time, but it would be okay to bring the cat for a little bit". The administrator stated on 7/15/25 that "eviction never came up at all" and (R1) is "doing great currently". The administrator explained the family signed a Pet Addendum that the facility could not charge for the pet and they never did charge, commenting "I never pushed the issue with the pet". The administrator stated the Addendum stated the cat had to have all vaccines up to date, contact information for the provider, and explained how staff has been taking care of the cat for the last 6 months because (R1) is not able to take care of the cat due to declining., *cont on 9099A-C-2.. *9099A-C-2.. On 7/11/25, the administrator stated that he called(R1's) responsible person last week, on a Tuesday or Wednesday, and asked if he could pick up the cat that same day. The administrator indicated he eventually asked if he could pick up the cat by Friday, when the family member indicated he could not pick up the cat on the same day or next day's notice. The Administrators explained the facility regularly communicated with the responsible person's spouse about bringing in cat food, and commented she "could see mom was declining and could not take care of the cat". The administrator stated again that the admission agreement is very clear- and he "never enforced" the requirements. The administrator stated at the time (R1) was admitted, there were (20) residents approximately residing in the facility, so he was more flexible in allowing a pet. Meeting notes from January 17, 2025, reflect that staff expressed (R1’s) declining ability to care for the cat, and the family and facility agreed that rehousing the cat may become necessary in future months. These notes also document (R1’s) increased support needed with ADL’s and scheduling a priority reassessment to determine (R1’s) updated level of care. Staff interviews revealed that (R1) was able to always feed the cat through early July 2025 but needed assistance towards the end with cleaning the litter box. The pet agreement was never enforced, and the owner ultimately asked the administrator to inquire if any facility staff members would like to rehome the cat, and one staff did. There was no evidence found that eviction was ever threatened and a 30- day notice was never issued. Based on information obtained, LPA finds this allegation to be UNFOUNDED- LPA finds the 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. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 14, 2025 · control 59-AS-20250711115916

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(5) · Plan of correction due date: Oct 28, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply: (5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents. This requirement is not met as evidenced by: Based on interviews and documentation reviewed, the Licensee did not ensure that resident (R1) was served a vegetarian and healthy meal on January 17, 2025, per their personal preference, which posed a potential health and safety risk to residents in care. (R1) was served deep fried chicken strips, French fries, and cole slaw for lunch.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: Licensee/Administrator agree to review the menu and ensure there is a vegetarian option listed for each meal. The Dietary Director will continue to reviewthe daily menu wih the Administrator, and DON, to ensure there is a balance of protein, carbs and vegetables/fruits served at each meal. Also consider serving cut up fruit and other snacks (cheeses, crackers) so residents can eat without difficulty. Documentation to be submitted by 10/28/25.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection and met with Karen Padilla, Director of Nursing (DON), and Kayla Peria, Director of Care and Admissions. LPA stated the reason for the inspection. The facility is licensed for (78) non-ambulatory or bedridden residents and has a hospice waiver for (20) residents. Currently, there are (15) residents under hospice care. There is a separate Assisted Living Unit (ALU) and Memory Care Unit (MCU) on site. During today's inspection, LPA and staff toured the interior and exterior of the ALU and MCU, including the dining rooms, activity areas and enclosed patios. (6) rooms were inspected in ALU and (4) rooms in MCU. Hot water temperature was taken in (2) resident rooms on each side and measured 111-112*F. The main kitchen was toured. There is sufficient 2+ day perishable and 7+ day non-perishable supply of food and a weekly menu is posted. There is a large monthly activities calendar posted in ALU and MCU. In all areas toured, there were no health and safety concerns, and the facility was observed to be clean, in good repair and odor free. The fire extinguishers were last serviced 8/25/25. All required postings are visible in the common areas. Inside temperature measured 72*F. Vehicle service records reflect regular maintenance is scheduled/completed and daily checks are done. Monthly Resident Council meeting notes were reviewed. LPA reviewed (7) resident files and (7) staff files. Files were organized, current and complete. Medications were reviewed for (2) residents and are being administered per orders. A pharmacy audit is completed every quarter to ensure compliance. All staff is cleared/associated and is completing the required initial/ongoing training, including First Aid/CPR. Recent Dementia Care updates to be added to the Plan of Operation to reflect regulation changes made in January 2025. There were no deficiencies observed. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 4, 2025

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection and met with Karen Padilla, Director of Nursing (DON), and Kayla Peria, Director of Care and Admissions. LPA stated the reason for the inspection. This report is being created to clear the Post-Licensing in the system. There are no deficiencies issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 4, 2025

Allegation investigated: Staff mismanaged resident's medications. Staff did not seek medical attention for the resident in a timely manner.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete the investigation and deliver complaint findings. LPA met with Karen Padilla, Director of Nursing (DON), and Kayla Peria, Director of Care and Admissions, and stated the reason for the inspection. During the investigation, LPA interviewed the Administrator, DON, Director of Care and Admissions and a family member of resident (R1), who is the subject of the investigation. LPA reviewed pertinent documentation relating to (R1), including but not limited to: the physician's report, pre-placement appraisal, appraisal, the Medication Administration Record (MAR), and charting notes. (R1) moved to the community in October 2024 with a diagnosis of CVA (stroke), vision impairment, Diabetes Mellitus 2, and requiring assistance with feeding, dressing, showers and incontinence care. Resident previously had a kidney transplant, was fully aware, conscious and coherent and able to follow instructions. Resident was sent to the hospital on May 8, 2025 for not feeling well and was later transferred to a skilled nursing facility. The results of the investigation are as follows: cont on 9099C-1.. Unfounded 9099C-1.. Allegation: Staff mismanaged resident's medications. The allegation states that staff has forgotten to give (R1) medications before, and don't check (R1's) blood pressure or blood sugars. The MAR was reviewed for months April and May 2025. The April MAR notes that (R1) was out of the facility from April 4 through April 26, and all medications were administered as prescribed from April 1 through April 4, and resumed on April 26. The MAR also notes that (R1) refused the medication,Brimonidine- eye drops, on April 27, 2025 (5:43 pm). Additionally, the MAR reflects that several new medications were prescribed to start on April 26 when (R1) returned to the community, and that they were administered as ordered. Facility charting notes document that (R1) was sent to the hospital on April 4, due to having blood in the urinal, and that (R1) was later transferred to a skilled nursing on April 21. The May MAR notes that (R1) was administered medications, as ordered, from May 1- May, 8 (morning dosage), and refused Insulin on May 7 (12:30 pm), even after staff explained the benefits and risks. Both MAR's note an order for staff to monitor (R1's blood pressure every Monday and Thursday, beginning on December 5, 2024, and more often if (R1) desired, and to fax the blood pressure log to (R1's) physician's office. The April MAR notes (R1's) blood pressure was taken on April 3 and 28, as resident was out of the facility from April 4-26. The May MAR notes (R1's) blood pressure was taken and logged on May 1, 5 and 8, prior to (R1) requesting to go to the Emergency Room. The charting notes state (R1) refused PRN medications for "nausea and dry heaves". Both the DON and Director of Care and Admission stated that (R1) would "refuse medications" and staff Med-Techs would take (R1's) basic vitals and would assist (R1) with "hand to hand" when testing (R1's) blood sugar. The DON stated she would assist with testing (R1's)sugar, if needed, and if (R1) refused insulin. Charting notes indicate (R1) "refuses daily to take insulin" after facility staff received (R1's) lab results back showing blood glucose levels were very high. The DON stated, and charting notes confirm, that the physician increased the pill form of Jardiance 10 mg, on December 12, 2024. The MARs note medication, Pioglitzaone HCL 15 mg was administered once every morning, as ordered (hold if blood sugar is less than 100), from May 1-8 and Insulin Aspart 100 Unit/ML was ordered with each meal, for diabetes management, starting on May 6, 2025. The MAR notes (R1) refused Insulin on May 7 (12:30 pm) but took took the medication with other meals from May 6-8. *cont on 9099C-2. 9099C-2.. (R1's) family member stated (R1) "had a blood sugar monitor with a reader but would ignore it while living at home", and would regularly tell him, "they won't take my blood sugar or blood pressure" at the facility. Based on information obtained, LPA finds the 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. Allegation: Staff did not seek medical attention for the resident in a timely manner. The allegation states (R1) had been telling the staff they were 'sick' and needed to go to the hospital approximately 1 week before being sent to the hospital. Charting notes document that on May 8, 2025, (R1) requested to be sent to the emergency room due to feeling nauseous and having "dry heaves" and was picked up by a non-emergency ambulance transport company at 10:15 am. The prior entry was made on April 21, 2025 and documents (R1) remained at the hospital as of April 21, 2025 after being diagnosed with Acute Hypoxic Respiratory Failure and Chronic Heart Failure and (R1) was treated with new medications prescribed (April 26, 2025). (R1) was transferred from the hospital to skilled nursing before returning to the community on April 26, 2025. Review of the facility's charting notes documents several times when (R1) requested to be sent out to the emergency room since moving in in October 2024, and was sent out: November 6, 2024; December 10, 2024; December 12, 2024; January 2, 2025; January 22, 2025; January 27, 2025; April 4, 2025; May 5, 2025. The DON stated "if anyone asks to go out, we send them". (R1's) family member stated (R1) didn't like being there and was at a Skilled Nursing Facility for 1.5 years prior to being moved to the facility, commenting "Oakwood Meadows is a nice facility but not a good fit for (R1)". The DON stated that (R1) preferred a medical type environment such as the hospital or skilled nursing rather than Assisted Living. Based on information obtained, LPA finds the 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 with the Administrator. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 22, 2025 · control 59-AS-20250513170952

Allegation investigated: Licensee is not preventing resident from being scalded by hot water while in care.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver complaint findings to a complaint received on June 17, 2025, and met with Director of Nursing (DON), Karen Padilla. LPA later met with Administrator, Danny Torgersen, and stated the reason for today's inspection. During the course of the investigation, LPA interviewed the Maintenance Director, Director of Nursing, (3) care staff and (2) other residents who live in the same wing of the facility as (R1). LPA also observed multiple pages of documentation showing when hot water was tested throughout the building. The results of the investigation are as follows: The allegation states (R1) has been scalded in the shower for the last two months and has reported the problem but staff have not fixed it, and (R1's) skin is being burned by the scalding water. *cont on 9099C-1.. Unfounded 9099C-1. Staff interviews conducted on June 18, 2025 revealed that (1) of (4) staff stated that (R1) mentioned the hot water in the shower felt "scorching hot"; however, this staff was not aware of any injuries to (R1) from the hot water. The Director of Nursing stated she is not aware that (R1) complained of the water being too hot or (R1) having any injuries from the hot water. Two (2) residents were interviewed who reside in the same part of the building that (R1) does. One resident stated she is able to adjust the hot water in the shower by turning the knob. The other resident stated she did not have hot water in the shower for two days and she had to take a cold shower. This resident indicated the problem has been fixed and staff told her a hot water pipe had been broken. The Maintenance Director stated he checks the hot water temperature throughout the building "every 1-2 weeks", specifically checking the temperature on the heater. The Director explained "each wing of the building has its own water heater" and he does a "cup test to ensure the temperature is less than 120*F". The Director showed LPA the temperature log of room checks and pointed out that (R1's) room was last checked on June 13, 2025, and the temperature was documented as 112*F. The Maintenance Director stated "(R1) has not complained of any hot water concerns, and the "water temperature for the whole building is set at 120*F", and the only exception is the dishwasher which is part of the septic system". The Director added "(R1) knows me and has no problem telling me if there is a maintenance concern", adding (R1) recently "complained of a lose door knob" in their room. The Director provided specific temperatures of the (5) rooms recently tested as: 112,111,112,112 and 110*F- averaging 111*F. LPA attempted to speak to (R1) on July 1,2025; however (R1) was out of the facility. LPA checked the hot water temperature in (R1's) sink/room, with staff (S1) present, and found it measured 104.4*F. (S1) explained that (R1) is independent with showering and will place the shower knob on the hottest temperature when warming the water but then does not move the knob to lower the temperature once the water has warmed, as (R1) wants "hot water". (S1) stated she never observed burns on (R1's) skin and most residents will put the shower knob in the middle to achieve the best temperature. (S1) explained that (R1) will often blame their roommate for using water from their sink, causing the water temperature to drop. (S1) stated she has told (R1) dishes are done from 5:30 pm to 9:00 pm, which can lower the hot water temperature. *cont on 9099C-1.. 90099C-2... LPA received communication from (R1) on June 30, 2025 that the Maintenance Director had recently tested the hot water in the shower and placed strips to prevent slipping. Then the Ombudsman tested the hot water, and it was "a bit more than luke warm then", causing the Maintenance Man to adjust the water. (R1) further stated the water pressure is fine now, except for "the water pressure going up and down when someone else is using a sink or shower" and (R1) is trying to adjust their shower time to later in the evening. Based on information obtained, LPA finds the 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. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 1, 2025 · control 59-AS-20250617165054

Allegation investigated: Staff not treating resident with respect.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver complaint findings to a complaint received on May 7, 2025, and met with Director of Nursing (DON), Karen Padilla, stating the reason for the inspection. LPA later met with the Administrator, Danny Torgersen, During the course of the investigation, LPA interviewed the Administrator, the DON, the Resident Habilitation Director, Ombudsman, (2) representatives from a placement agency and resident (R1), who is the subject of the investigation. LPA reviewed documentation relating to (R1), including but not limited to, resident appraisal, physician's report, Care Conference case notes, other case notes and email communications with the Administrator. The results of the investigation are as follows: Resident (R1) moved to the community on January 31, 2025 with the primary diagnoses of Psoriatic Arthritis, chronic low appetite and severe PTSD. (R1) was independent with Activities of Daily Living (ADL's), including medications, and was able to follow instructions, communicate needs and able to leave the facility alone. It's noted on the physician's report that (R1) could be depressed. **cont on 9099C-1.. Unsubstantiated 9099C-1.. The Pre-Appraisal completed on January, 31, 2025, notes (R1) is ambulatory, is independent with transferring and toileting, needs stand-by assistance with bathing/dressing and medications, and needs daily monitoring due to behaviors. Allegation: Staff not treating resident with respect. The allegation states (R1) feels like the Administrator “belittles” and “degrades” them, and does not respect them The Care Conference notes, dated May 6, 2025, note that during the discussion, (R1) expressed that they “felt the Administrator was speaking negatively about them and asked if he had anything positive to say”. The notes say the Administrator replied that “it was not personal but that Oakwood Meadows now only accepts residents with RH services” and (R1’s) change in RH status makes them no longer eligible for their program”, and confirmed “RH is now a facility requirement and claimed (R1) was not receiving services consistently, which prompted disenrollment” from the program. A social worker stated that the Administrator “can come off a bit harsh- the way he talks"; he “tried to be as respectful as possible, but it's his personality that he is a little intimidating and would address (R1) like "you have this problem" as if talking to a child. The Ombudsman stated to LPA on May 19, 2025 that he "did not observe the Administrator to be condescending or rude to (R1) and (R1) could not provide an example when asked". The Administrator stated via email on May 13, 2025 that (R1’s) “demands are extreme and constant though our responses to their demands are immediate and consistent”. Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED-A finding that the complaint 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. Copy of report provided. 9099A-C1. .. The Administrator stated via email, on May 13, 2025, that (R1) “has never been notified of, or reported to of the eviction process…There have never been notices sent to (R1) regarding eviction”… nor “have there been any discussion of (R1) being evicted”. A Care Conference was held on May 6, 2025 with (R1), their social workers, Ombudsman and (3) facility managers. The Ombudsman asked for clarification at this meeting regarding the eviction (R1) feels she has received, and the Administrator stated (R1) had verbally given notice to the facility and mentioned moving out “multiple times over the past month”. The notes state that (R1) commented that her “anxiety and PTSD sometimes lead her to say things she doesn’t mean, such as threats to move into the car”. According to the notes, the Ombudsman tried to explain to (R1) that their statements still “carry weight, and that the facility seems to be taking her at her word other than initiating eviction”. The notes state the Administrator confirmed that “no formal 30-day notice has been issued and agreed to allow (R1) to remain at the facility for another 30-days, emphasizing written move-out notice is requested from (R1)”, and the Administrator agreed (R1) could stay at the facility beyond 30-days if no alternative placement is found. The notes further state “The meeting concluded with mutual agreement that (R1) may remain at Oakwood Meadows while continuing to search for an alternative placement”. The Care Conference notes document concerns made by the Administrator that (R1) has been frequently threatening to move out and live in their car. The Ombudsman added that (R1)’s “repeated verbal threats can be interpreted as notice and recommended that Oakwood Meadows notify licensing of such statements for documentation”. (R1) responded that their threats were made due to feelings of anxiety and frustrated and asked if they could be “retracted”. (R1) confirmed with the LPA in May 2025 they had not received a written eviction notice since living at the facility. Based on information obtained, LPA finds the 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. *cont on 9099A-C2.. 9099A-C-2.. Allegation: Staff not providing resident transportation to doctors appointments. The allegation stated staff (S1) was instructed by the Administrator to inform (R1) that she is no longer on the transportation service due to unenrollment from the RH program. LPA was provided with a transportation schedule for Tuesday, May 6, 2025 showing (R1) received transportation that day, at 8:30 am, to a medical appointment. The Administrator explained via email on May 13, 2025, that the facility “has never denied this resident access to transportation” to any appointments, (R1) has a car and has driven it many times to their appointments… (R1) is allotted three transports, as needed, for medical related appointments per month”.. and resident must use their ”approved transports”. The Administrator later emailed the LPA on May 19, 2025 that (R1) has “four transports per month that is covered on their insurance”, and “we attempt to use those transports first before we drive (R1) ourselves”. The email also states, in part, that (S1) “does not coordinate anything, just follows the schedule set for that day and is not responsible for making any appointments for (R1) or cancelling any appointments. When there is a conflict in scheduling, we will use our own transport van”. LPA interviewed staff (S2) who is the Transportation coordinator. S2 stated she would assist (R1) in scheduling rides for medical appointments and (R1) never missed, or was late, to any of their scheduled appointments. (S2) stated she is not aware of a ride limit a resident can receive and explained that (R1) was also able to use their medical transport for non-emergencies, which she used before. Additionally, (S2) stated that the facility would have “emergency appointments” that would take priority and she did have to tell (R1) on one occasion that she needed to reschedule the appointment and gave (R1) one week to schedule one time. (S2) stated she would take direction from the Med-Tech and the Director of Nursing, who maintain the ride schedule, if a ride transport needed to be cancelled. Based on information obtained, LPA finds the 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. *cont on 9099A-C3.. *9099A-C-3.. Allegation: Staff retaliating against resident. The allegation states that the Administrator later told (R1) they have to be out of the facility within 30 days, after (R1) unenrolled from the RH Program. (R1) stated they felt the program was not benefiting them and decided to un-enroll and after she un-enrolled from the program, (R1) started to have issues. The Administrator stated in an email, sent on May 13, 2025, that “(R1) was originally enrolled in the RH Program when moving into the facility”; however, within the first month, (R1) rejected participation in the program, which offered them more time spent with specific assistants throughout the day. The email references other actions the facility has taken to “accommodate (R1’s) requests”, relating to their roommate situation and room assignment. The Administrator communicated via email to the Department on May 13, 2025, that (R1) made multiple verbal threats to him, and many other staff, about moving out of the building and “verbally gave notice”. The email states that the facility has taken the “threats” seriously and are working with (R1’s) placement agency to find a facility that is better able to meet (R1’s) mental health needs. Based on information obtained, LPA finds the 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. Allegation: Staff does not provide a safe environment for resident. The allegation states (R1) does not feel safe at the facility, due to interaction with staff. LPA reviewed notes from May 6, 2025, when a care conference was held with (R1), their social workers, Ombudsman and (3) facility managers. The notes indicate that (R1) stated at the start of the meeting she felt “scared and threatened” by a prior meeting with (2) of the managers. The notes state that (R1) felt they were being pushed to move out of the facility due to no longer being enrolled in a particular program that some of the residents are enrolled in. *cont on 9099A-C-4.. *9099A-C-4.. The Administrator emailed the Department on May 13, 2025 that the facility has taken many steps to accommodate (R1) and their requests, including changing roommates and room assignments, and making personnel changes. The email states the facility has never received a complaint that a resident is unsafe and (R1) has voiced concerns of “feeling unsafe when hearing sounds, temperatures, night-lights, television noises” and other noises such as voices. Based on information obtained, LPA finds the 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. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 59-AS-20250507155152

Allegation investigated: Staff are not caring for resident's wounds. Staff are not assisting resident with topical medication. Staff are allowing resident to sit in soiled bedding.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver investigative findings for a complaint received on March 25, 2025. LPA met with Director of Nursing, Karen Padilla, and stated the reason for the inspection. LPA later met with Kayla Peria, Care and Admissions Director. During the investigation, LPA interviewed the Administrator, Director of Nursing, Care and Admissions Director, a care staff and resident (R1). LPA reviewed pertinent documentatation for (R1) including but not limited to the physician's report, hospital discharge paperwork, Medication Administration Record (MAR) for February 2025 and March 2025. The results are as follows: Resident (R1) moved to the community in December 2023 with a diagnosis of COPD, Chronic Respiratory Failure, and used oxygen. Resident was their own responsible person and could schedule medical appointments. *cont on 9099C-1.. Unsubstantiated 9099C-1.. Allegation Staff are not caring for resident's wounds. The allegation states (R1) has open sores all over their body from head to toe that are actively bleeding and staff are not cleaning them and resident has not had a diagnosis for over a year. On 3/25/25, LPA observed (R1) resting in bed and to have an extensive "rash" on their arms, legs, bottom of the feet and ears. The Director of Nursing (DON) was also present and showed LPA the bottom of resident’s foot that had blisters, explaining the skin condition starts out as blisters but then turns into a rash that is bleeding. (R1) stated she has gone to their health care provider emergency room at least 15 times to treat the rash, indicating they are "trying not to itch, but it still itches and burns". (R1) confirmed they have "nerve damage”, “staff puts on all lotion". and the “lotion helps”. (R1) stated the "rash" started with cyst on the back. On 3/25/25, the DON stated resident (R1) was at the hospital for (9) hours yesterday due to blisters and has a dermatology appointment on June 2, 2025. The DON confirmed that the hospital ER did not do a skin scrape to test for scabies. The DON confirmed she can only minimally help (R1) with on-line scheduling on her phone and that (R1) has an auto immune condition that could be contributing to the rash. Hospital documentation shows (R1) went to the emergency room on 3/24/25 and was prescribed two new prescriptions: Clobetasol(Temovate) 0.05 % ointment to be applied to the affected area two times daily for two weeks; and Doxycycline Monohydrate (Avidoxy) 100 mg – 1 tablet to be taken two times daily for 14 days. The hospital discharge paperwork also notes that a follow up dermatology appointment was scheduled on 6/2/25. A person that knows (R1) stated that the client can’t seem to get an accurate diagnosis as to what the sores are as she has been told they were scabies, but that stated that no one has scabies for over a year. LPA reviewed hospital documentation showing (R1) visited the emergency room on 3/17/25 for the skin rash and was prescribed a new prescription for Hydro-Cortisone (Hytone) 1% top cream to apply to affected area(s) one to four times daily and given information on rash care. No future appointments were noted on the discharge paperwork. *cont on 9099C-2.. 9099C-2.. Additional hospital documentation reviewed shows (R1) was seen in the emergency room on 2/7/25 with two new prescribed medications: Cetirizine (Zyrtec) 10 mg- 1 tablet to be taken twice daily as needed for itching; and Doxycycline Monohydrate (Avidoxy) 100 mg to take 1 tablet two times daily for seven days. Resident was also provided with information on Cellulitis. No future appointments were noted on the discharge paperwork. In April 2025, after (R1) was hospitalized, the facility confirmed that the rash was determined to be a staph infection during a resident care conference. On 5/9/25, the DON indicated she received an email earlier that day stating that (R1) would not be returning from the skilled nursing as (R1) was receiving antibiotics to treat the skin rash that "flared up" more due to an auto immune disease (R1) has. The DON confirmed the rash (R1) has had for months is "not scabies. The Care and Admissions Director stated that resident was sent to the doctor many times, including to the emergency room, and (R1) received many different diagnosis related to the rash, including, cellulitis scabies, lice (on head) and MRSA, and the doctors were not sure what the rash was. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint 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. Allegation: Staff are not assisting resident with topical medication. The complaint alleges that resident (R1) can’t move their arms and the staff don’t help by applying topical medication on (R1). Resident (R1) stated to LPA and the Ombudsman on 3/25/25 that they received a 10-day prescription for the antibiotic, Doxycline Monohydrate 100 mg and for a topical creme, Clobetasol, to be applied two times/day for two weeks. The MAR for March 2025 notes this medication was administered as ordered, and was not given on 3/30/25 and 3/31/25, in the evening, due to resident being out of the facility. The MAR for February 2025 notes on 2/8/25, the medication, Doxycycline Monohydrate 100 mg tablets were to be given twice daily for seven days and were administered accordingly. Also prescribed on 2/8/25, Hydrocortisone 2.5% ointment, to be applied twice daily to affected area(s) for the rash. *cont on 9099C-3.. 9099C-3.. A third medication was prescribed on 2/8/25 to be applied two times daily to other areas of the rash. MAR shows staff initials for each day/time as prescribed for each of these (3) medications.On 2/23/25, PRN medication for the rash and symptoms was given at 9:04 am- Triamcinolone Acetonide .1% ointment and Cetriizine HCL 10 mg tablet for itching. Additional PRN medications were given on Feb 2, 5, 8 and 10 for itching related to the rash. One staff stated the Med-Techs are supposed to put cream on the rash and they put it on "here and there"- it seemed like some dosages may have been working and others have not. The DON stated (R1) has a problem with her shoulder and with transferring but has been allowing staff to apply topical crème on. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint 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. Allegation: Staff are allowing resident to sit in soiled bedding. The allegation states that the staff don’t clean (R1’s) wounds or change the bed sheets the sheets have old blood stains from the sores. On 3/26/25, one staff confirmed "the caregivers will change the bedding- we put a towel under her and a washable chux and staff will change the flat/top sheet more". This staff confirmed staff will "often use a fitted sheet too", commenting that "sometimes (R1) will refuse staff to change their sheets, and staff will change their sheets at least once daily when the rash was bleeding". The Care and Admissions Director stated that all care staff and housekeeping staff are trained to change the sheets every time they notice any stains or soiling, commenting if the sheet is "super soiled", staff will change it right away. The Director explained that staff also use a washable chux, along with the sheets, that is extra large and covers the majority of (R1's) body, and that the chux will be changed more often than the sheets. The Director explained that (R1) would use oxygen causing her to sweat more and become itchy with the rash, mostly on their neck, shoulders and ears, commenting "we were very careful with (R1)" to ensure they had clean bedding and received showers as often as needed. *cont on 9099C-4.. 9099C-4. In Nov/Dec 2024, staff began requesting (R1) sign when a shower is offered, given or refused since (R1) would often agree initially and then change her mind later. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint 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. Copy of report provided. 9099-A-C-1.. The Administrator confirmed that staff and (R1) are still signing for showers that are given, offered and/or refused. This process was implemented months ago with (R1) since they would often agree to a shower and then later change their mind. On 4/8/25, the DON stated to LPA that staff were encouraging (R1)to take showers more frequently, the same staff have been working on the hall where (R1) lives, and she is not aware of anyone else with rashes in assisted living. Based on information obtained, LPA finds this 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. Allegation: Staff made inappropriate comments towards resident. The allegation states staff (S1) talks about the resident (R1) saying, “ (R1) is a problem child. We’ll get to (R1) when we get to (R1). (R1) is a nuisance.” One care staff stated "(R1) calls thyself a problem child" and hasn't heard a staff or manager say that. The DON stated she has never heard any staff refer to (R1) or any other resident like that. The Care and Admissions Director stated staff would regularly speak to (R1) in pairs, so there is a witness as to what was said. (R1) never complained to the Admissions Director about any staff making this comment. Based on information obtained, LPA finds this 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. Copy of report provided.the state’s words, verbatim · CDSS document, May 22, 2025 · control 59-AS-20250325082305

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to follow up on an incident report submitted to the Department on/around May 15, 2025 for an incident that occurred on May 13, 2025. LPA met with Director of Nursing (DON), Karen Padilla, and stated the reason for today's inspection. LPA discussed the incident more with the DON, who confirmed that resident (R1) was observed to have a paring knife in their room on May 13, 2025. The DON stated (R1) moves around the facility a lot but is not sure if the resident moved in with the knife, as it was wrapped in a paper towel, or it was obtained form the facility kitchen. The incident report submitted states that (R1) pulled a knife out to a Med-Tech staff (S1) and stated they are "stressed out". A second Med-Tech (S2) immediately intervened and asked that resident give the knife to her, which the resident refused to do a few times. The incident was then reported to the DON, who suggested resident be sent out for further medical evaluation. Resident was sent out and hospitalized overnight, returning the following day at 3:40 pm. Multiple lab tests were performed, including liver ultra sound, and the ammonia level, which all returned within normal limits. Additionally, a psych test was done which approved resident to return to the facility on 5/14/25, but with medication changes made. LPA reviewed facility documentation which shows (R1) has a diagnosis of dementia and can display aggressive, wandering and sundowning behaviors. Facility has increased monitoring for (R1) and will install code locks for the kitchen doors to ensure resident does not have access to the kitchen. Per Title 22 Regulations, Division 6, Chapter 8, the following deficiency is cited on 809-D page. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, May 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: May 23, 2025

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on documentation reviewed and interviews conducted, the Licensee did not ensure that resident (R1) did not have access to a small paring knife, on/around May 13, 2025, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: The DON stated new code locks will be installed on the kitchen doors. Resident's family was spoken to about resident having a wrapped knife in their room. Staff training to be conducted how to use the new code locks and to ensure all staff are equipped to respond in this type of situation. Discuss with family members to regularly check residents' belongings are safe for the community. Documentation of training by 6/6/25.

Type of visit: Case Management - Other

On May 14, 2025, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains conducted an unannounced case management visit . This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES. LPAs met with Administrator Daniel Torgersen and stated the purpose of visit. Facility understands this is an Immediate Exclusion effective May 14, 2025 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.the state’s words, verbatim · CDSS document, May 14, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management investigation. LPA met with Director of Nursing (DON), Karen Padilla, and stated the reason for the inspection. LPA discussed recent incidents reported to the department and obtained individual Pre-Assessments and Care Plans for the following residents: Resident (R1) recently obtained an updated Physician's Report (LIC602) and faxed a copy to the department reflecting an updated change. The DON stated one of the pages appears to have been completed by a different person than the person who completed the other pages, and the faxed dates do not match either. The DON stated she is waiting for a return call from the doctor to discuss further. On April 19, 2025 (6:50 pm), Resident (R2) pushed resident (R3). (R3) retaliated by pushing (R2) back against the wall. (R2) was taken to their room, assessed and observed to have a skin tear on the left arm and a possible hip fracture. (R3) was redirected back to their room. Hospice staff was contacted and advised (R2) have an x-ray taken, so (R2) was sent out. (R2) was diagnosed with a hip fracture, had surgery on 4/20/25 and returned to the community and later passed on May 2, 2025, while under hospice care. On April 20,2025, resident (R4) was observed by a Med-Tech staff to be physically and verbally aggressive with another staff and was sent out for further medical evaluation. (R4) returned with a change in medication -Seroquel was increased to 50mg at bedtime for agitation, and a PRN order was also added - 100 mg to be added three times per day, as needed, for agitation. The DON stated resident is showing less aggression. It appears the facility acted timely in seeking outside medical help. There are no deficiencies being issued. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, May 9, 2025

Allegation investigated: Licensee did not ensure that resident was administered their medications according to physician's instructions while in care. Licensee does not ensure that residents are provided with food that is of good quality while in care. Staff did not respond to resident's requests for assistance as necessary while resident was in care.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to the remaining (3) allegations for a complaint received on January 8, 2025. LPA met with Administrator, Danny Torgersen, and stated the reason for today's inspection. LPA met with Director of Nursing, Karen Padilla, later during the inspection. During the investigation, LPA interviewed multiple staff and several residents and reviewed documentation related to resident (R1), who is the subject of the investigation. Documentation included (R1's) physician's report, charting notes, physician's orders and the Medication Administration Record (MAR) for December 2024. The results of the investigation are as follows: (R1) moved in on/around June 28, 2024 and resided in the Assisted Living Unit. The physician's report (October 31, 2024) notes (R1) has multiple diagnoses, but does not have Mild Cognitive Impairment (MCI) or Dementia, is able to leave the facility unsupervised, and can determine and communicate their need for prescription/non-prescription medication. *cont on 9099C-1.. Unsubstantiated 9099C-1.. Allegation: Licensee did not ensure that resident was administered their medications according to physician's instructions while in care. The allegation states the facility discontinued (R1’s) medications so (R1) was not provided the medications they needed, including Hydroxyzine, Buspirone, Trazadone, Eye Drops for macular degeneration, and other anti-anxiety medications, which caused (R1) to suffer for a long time while living at the facility. NOTE: The Department investigated a related allegation (Facility withheld resident’s medications upon move out) in January 2025, and those findings were determined to be Unfounded. Physician's orders, dated August 15, 2024, note (R1) had (18) scheduled medications, including: Trazodone 100mg and Hydroxyzine HCL 50mg, and (13) PRN medications including Buspirone 10 mg and Propyl Glycol/Peg/.3/.4% UD (for dry eyes). There is not a prescription for any other eye drops. Physician's orders, dated December 24, 2024, list (22) scheduled medications and (12) PRN medications. Also noted on this documentation are several discontinuance orders, including for (3) psychotic medications, 24including for Buspirone 10mg tablet, Hydroxyzine HCL 50 mg tabs, Trazadone 100mg and several PRN medications, including the Propyl Glycol/Peg/.3/.4% UD. There is not a prescription for another eye drops. The MAR for December 2024 shows that Buspirone 10 mg was administered, twice daily, as ordered, and Trazadone 100mg tab was administered daily, as ordered, at bedtime, through December 28, 20. The MAR also shows Hydroxyzine HCL 50mg, was administered three times daily, as ordered, except for 5:00 pm dosage on December 7 and 26, through December 28, 2024, also. There are no notations indicating why this medication was not administered at these two times. Additionally, the MAR also shows medications Gabapentin 300mg, Buspirone 10mg, and Prazosin HCL1 mg have missing initials on the same days/times, suggesting a staff error. The MAR shows PRN Propyl Glycol/Peg/.3/.4% UD, was not issued during the month of December 2024 and notes all other medications were administered, as ordered. There are no additional eye drops listed on the MAR that they were administered. *cont on 9099C-2.. 9099C-2.. (R1's) charting notes do not have any entries for December 7 and 26, related to medications and only that (R1) was showing behaviors on the morning of December 26, 2024. Charting Notes from 12/27/24 document that (R1) asked for Hydrocxazine, and when staff told (R1) it’s a scheduled not PRN, (R1) began cussing at staff/calling them derogatory names and accusing the facility of lying and stealing their medications. Charting notes from 12/30/24 show (R1)was placed on alert charting for “new supplements” and was prescribed “new medications, commencing on 12/30/24 0800 hours: fish oil 1200 MG, Preservision A-reds, Probiotic Blend, D-Mannose 500 MG. LPA spoke with a Med-Tech staff who was familiar with (R1)'s medications and stated (R1) took mostly supplements, including an eye vitamin, and did not recall (R1) taking any eye drops. This staff indicated that (R1) was very particular about the medications they took, was aware of each one, and would regularly question staff about it. One of (R1's) prior roommates stated to LPA that "(R1)had problems with medications daily and would count them and then argue with staff everyday" that (R1) wasn't given the correct meds. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint 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. Allegation: Licensee does not ensure that residents are provided with food that is of good quality while in care. The allegation states when (R1) lived at the facility, the food was terrible and barely edible and (R1) often had to spit it out. It's also alleged that the food is served cold. The Culinary manager stated he does not recall (R1) living at the community and was out of the facility during the month of November 2024. The manager explained in January 2025 that the facility's main convection oven has always worked, and the prior "steam table" had a small leak, but it has been replaced. On January 17, 2025, LPA observed the food warmer to show a temperature of 148*F and plates are being placed there to be warmed before serving food on them. *cont on 9099C-3.. 9099C-3..The manager explained that staff will "take temperatures of all food at every meal" and ensure the temperatures are "per normal cooking temperatures". The manager added that during November 2024, there were "no issues with the food temperatures, per the paperwork that was completed", asserting "the food is never served cold, except for sandwiches and salads". A caregiver staff who assisted (R1) indicated that (R1) "never complained about the food and would ask for sandwiches, salad, fruit and the culinary manager would make it" and (R1) "ate all of the food and she never observed (R1) to complain about it". During the interview, this caregiver staff brought a warm plate to LPA from the kitchen where LPA was able to confirm the plate was "warm-hot" to the touch. The Department received additional information in February 2025, relating to another resident (R2). The report stated that this kitchen does not know what resident likes or dislikes. LPA discussed this resident with the culinary manager who indicated he has been meeting weekly with (R2) to provide a monthly menu and discuss alternative options, if needed, to the menu items. LPA met with (R2) on April 10, 2025 to discuss their concerns. (R2) showed LPA a copy of the April menu and notations they made where they don't like the food preferences. (R2) stated the kitchen staff are "trying" and it's better but (R2) "still struggles to get food they likes- stating they eat a lot of yogurt, cottage cheese to get protein. Additionally, (R2) expressed the facility doesn't offer an evening snack, which is needed since dinner is served early around 4:30-5:00 pm, and agreed that Protein Drinks (ie. Ensure) would be great to have available in between meals. (R2) stated lasagna, spaghetti, enchiladas, and quiche with spinach, are favorite foods served and the when they started doing "dinner salads". grilled cheese or another sandwich have been the only alternatives to the main menu entree, until recently with "dinner salads" offered. LPA spoke to (1) additional resident on April 11,2025, who indicated they do not like most of the food, due to the taste or type of food, and grilled cheese sandwiches are their first choice of a meal. The weekly menu is posted outside the main dining area and all meals appear to be balanced with a main entree, vegetable or fruit side, beverage and dessert. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint 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. *cont on 9099C-4. 9099C-4..Allegation: Staff did not respond to resident's requests for assistance as necessary while resident was in care. The allegation states staff would not respond when (R1) would pull their cord to request assistance and (R1) "could have died" because of staff ignoring the requests for assistance. A care staff who provided care to (R1) was asked if staff answer (R1's) calls promptly. This staff stated "Yes, we always answer- there is a dispatcher here seven days per week and the lead maintenance staff tests the buttons weekly. This staff commented, "I treated (R1) like a VIP and staff was extra nice to (R1)". Interviews conducted revealed that (R1) had multiple roommates and was initially friendly to people but later became upset and accusatory towards many. LPA spoke to (R2) about concerns brought to the Department's attention in February 2025. (R2) stated that most of the time staff respond promptly, within (30) minutes on the "am" and "pm" shifts, but staff often do not respond timely during the night time hours. (R2) offered an explanation that "NOC is really bad because there is no one at the reception desk during graveyard to monitor the calls". (R2) added they don't think NOC staff are sleeping, but that there just aren't enough staff" at this time, stating "2 staff is "not enough", to cover Memory Care also. The Administrator and Director of Nursing confirmed there are (5) total staff on overnight shift and staff will cover where needed in either unit. (R2) was asked about additional concerns brought to the department's attention. (R2) stated they feel staff do not provide as complete incontinent care as possible, including using wipes with a urine soiled diaper, due to being "rushed" and having to get to the next resident. (R2) confirmed they will hear staff's radio announce another resident needs assistance, so staff have to go. LPA and (R2) discussed one additional issue related to incontinent care. (R2) explained that (R2) was providing their own wipes but ran out of briefs and liners last Sunday, April 8, explaining additional incontinent supplies are kept upstairs in the supply room and there is one staff who has a key and she was off work on the weekends. (R2) stated last Sunday was the first time it was "that bad" and staff had to really look for supplies. The Administrator and Director of Nursing stated the supply room door has a combination lock and not a key lock and at least (1) staff on every shift is able to access any needed supplies,and there is not insufficient staffing during the night time hours. The facility stated reports for pendant call response times are not available after (30) days and (R1) moved out on December 30, 2024. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint 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. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 11, 2025 · control 59-AS-20250108113928

Allegation investigated: Staff did not safeguard resident's possessions while in care. Staff did not ensure that resident's laundry needs were met while in care. Staff did not accord dignity to resident while in care.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to continue the complaint investigation and deliver partial findings to a complaint received on January 8, 2025. LPA met with Kayla Peria, Director of Care and Admissions, and stated the reason for the inspection. Director of Nursing, Karen Padilla, met with LPA at 12:15 pm. During the investigation, LPA interviewed multiple staff and several residents and reviewed pertinent documentation related to resident (R1) including physician's report, charting notes, incident report and other documentation. The results of the investigation are as follows: Resident (R1) moved to the community on June 28, 2024 and moved out December 30, 2024. (R1's) physician's report (October 31, 2024) notes they have multiple diagnoses, including Parkinson's Disease, does not have Mild Cognitive Impairment (MCI) or Dementia, is able to leave the facility unsupervised, and can determine and communicate their need for prescription/non-prescription medication. *cont on 9099C-1.. Unsubstantiated 9099C-1.. Allegation: Staff did not safeguard resident's possessions while in care. The allegation states staff did not return clean laundry as (R1) would not get many of their items back. Sheets, certain clothing, slippers and phone charger went missing, and were never returned to (R1) upon move out. LPA spoke to the laundry staff in Assisted Living who indicated she did not work at the community when (R1) resided here. The staff explained the laundry processes and that each resident has a laundry bag to collect clothing that needs laundry, laundry is completed at least weekly for each resident, and returned the same day. This staff stated there has not been a "Lost and Found" bin since she started in February 2025 and in general, residents are very happy with the laundry service. LPA spoke to a care staff who stated (R1) "would take other residents' items, including from her roommates" and she found their photos in (R1's) closet one time and asked (R1) to return the items". This staff stated (R1's) phone was not missing as they were on their phone all the time and carried it around". This staff stated that none of her items, such as slippers or clothing, went missing and (R1) was given wipes and pull-ups the last four weeks too before they left". This staff further explained that (R1) was a tall person and their clothes, pants, would not have fit the staff at the community. The Administrator stated there is "no record of (R1) having a black iPhone or that it was reported missing" and that (R1) was "in his office all of the time" also. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint 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. Allegation: Staff did not ensure that resident's laundry needs were met while in care. The allegation states staff rarely took (R1's) laundry to have it cleaned. A laundry staff explained that each resident has a laundry bag to collect items needing laundering, and laundry is completed weekly for each resident. This staff stated residents are generally very happy with the laundry service but did not work at the community when (R1) lived here. A care staff stated (R1)"wanted her laundry done" and so I would talk to them about that, adding "I went out of my way to do laundry for (R1)-I did theirs privately every day or other day- I would personally wash it and return it to them" and confirmed "staff labels all resident's clothing", explaining "We have a separate laundry lady who labels all resident clothes". Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED. *cont on 9099C-2. 9099C-2.. Allegation: Staff did not accord dignity to resident while in care. The allegation states that (R1) was treated horribly by staff while living at this facility. A main care staff confirmed she recalls prior resident, (R1) and she did not have any problems working with them however, (R1) "didn't like everyone and was aggressive and verbally mean to staff and residents". This staff further explained "every staff was always nice to (R1), commenting "we train the girls for kindness". A manager stated (R1) was friendly with staff and residents initially but then would turn on them and accuse of them of stealing or lying. LPA spoke to (2) prior roommates who said (R1) was verbally threatening and mean to them. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint 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. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 10, 2025 · control 59-AS-20250108113928

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

Allegation investigated: Due to lack of supervision, resident was assaulted.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete the complaint investigation and deliver findings for a complaint received on January 23, 2025. LPA met with Kayla Peria, Director of Care and Admissions, and stated the reason for the inspection. Director of Nursing, Karen Padilla, met with LPA at 12:15 pm. During the investigation, LPA interviewed multiple staff and several residents. Documentation was also reviewed, including, incident reports submitted to the Department, and pertinent paperwork from resident (R1/R2/R3's) files. The results of the investigation are as follows: The alleagation states that resident (R1) was assaulted several times in the last (4) months, (R1) is independent, and the Administrator refuses to let (R1) leave the building. There were no specific details on when the alleged assaults occurred. *Cont on 9099C-1.. Unsubstantiated 9099C-1. Resident (R1) moved to the facility on/around September 4, 2024 with a primary diagnosis of Epilepsy due to seizure activity, and a secondary diagnosis of Hypothyroidism and Mild Cognitive Impairment. The Physician's report dated August 30, 2024, notes (R1) can be confused at times, does not show inappropriate behavior, is able to follow instructions and communicate needs and can be depressed. The care plan notes (R1) is in "overall good health", is independent and ambulatory and needs supervision and cueing with bathing and assistance with medications. (R1) stated to LPA end of January 2025 that they are "independent" and want to move from the facility and live on their own. (R1) stated their prior roommate (R2) "pummelled them and hit them over and over" on/around November 12, 2024, the Director of Care and Admissions pulled (R2) off of (R1), and they informed the managers and Ombudsman following the incident. (R1) stated (R2) assaulted them due to them turning off the heater in the room. (R1) stated they went to the hospital, a police report was filed, and they returned to the community in the morning on November 12, 2024. (R1) added that (R2) "verbally assaulted them on November 13, 2024 and then tried to physically assault them again on November 14, 2024, both for "no real reason". (R1) stated to LPA on the same day that resident (R3) attacked them in the dining room on October 31, 2024, during a Halloween party, and later again, at the puzzle table in the common area. (R1) stated these incidents were immediately reported to facility management. Charting notes for (R1) shows (R1) regularly refused scheduled medications since moving in and told staff the doctor discontinued them. The Department received an incident report for an incident occurring on November 11, 2024 (6:00 pm) where (R1) called 9-1-1 to report their roommate (R2) and another resident (R3) was stalking them, and (R1) told the police they wanted to move out. The incident report and hospital discharge paperwork note (R1) returned at 10:30 am on November 12, 2024. Hospital paperwork notes (R1) was diagnosed with Urticaria (hives). The incident report states there were no new orders given at the hospital, resident has been refusing medications at the community. The facility submitted a prior incident report for an incident on November 6, 2024 when (R1) called 9-1-1 stating they were having a heart attack. (R1) was taken to the hospital, had labs and various tests done that returned with results within normal range. Returned returned the next day with no new orders. (cont on 9099C-2..) 9099C-2.. LPA spoke to resident (R4), also a prior resident of (R2), who stated they never witnessed (R2) physically attacking another resident, but (R2) told them one time they "threw a cup of water in another roommate's face because they didn't like the roommate snoring". (R4) stated (R2) verbally threatened them one time, and they were moved to another room. LPA interviewed resident (R3) in March 2025. (R3) indicated they are one of a few residents who like to walk in the building and (R1) is another resident who does also. (R3) stated they have only talked to (R1) as (R1) is "nice" and they have never followed them or physically attacked them. (R3) showed LPA the number of steps they take each day as they walk throughout the building on their cell phone. One staff stated to LPA in March they were told from other staff they witnessed (R2) hit (R1) and harass them, but this staff was not at work that day. This staff stated (R2) "threatened resident (R5) who is currently at the hospital, along with her roommates, (R1) and (R6) and threw water on them". Multiple other staff stated they only heard "verbal exchanges" between (R1) and (R2) while they were roommates for (12) days. Multiple staff interviews with managers confirmed that (R3) keeps to themself while walking, participates in activities and has never been observed to attack or physically touch any resident. Charting notes for (R3) note that they pushed and kicked resident (R7) on November 12, 2024 and tried hitting resident (R8) on December 14, 2024. The Activity Director stated (R1) is "pretty independent" and likes to exercise and do laps around the building, and she has never noticed (R1) to have any issues with (R3) as (R1) spends a lot of time in their room. This Director stated (R3) is very helpful and has never been observed to physically try to touch any resident. Both the Activity Director and Maintenance Director stated they have "never seen (R1) and (R3) interact". The Care and Admissions Directed stated that the internal investigation was completed and at the time, (R1) and(R2) were both interviewed, there were "no bruises or scratches" observed, commenting they "argued a lot over the volume of the television, and (R1) said (R2) was going through (R1's) stuff. (R1's) family member stated there was never any evidence that (R1) had any bruising or injuries from the alleged attacks. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint 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 with administrator and report provided.the state’s words, verbatim · CDSS document, Apr 10, 2025 · control 59-AS-20250123091955

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada and Ombudsman arrived unannounced to conduct a case management inspection. LPA met with Director of Nursing, Karen Padilla and Administrator, Danny Torgersen, and stated the reason for the inspection.LPA, Ombudsman and both facility managers discussed the following incidents recently reported to the Department, as follows: Resident (R1) had an altercation with resident (R2) who entered their room on March 23, 2025 (7:00 pm). Staff stated (R2) may have wandered in (R1's) room, mistakenly, and (R1) may have tried to be aggressive with (R2) and then (R2) may have hit (R1) on the lip. Both residents were sent to the ER. (R1) returned with sutures to their upper left lip and (R2) remains in the hospital as they have shown behaviors there. Resident (R3) was observed to be on the floor with their left eye cheek swollen on March 22, 2025. Staff stated resident fell going to the bathroom. Resident was sent out for emergency treatment and returned the same day. Resident (R4) was found on the floor in the bathroom on March 22, 2025. Resident was observed with a skin tear on their left forearm and a fracture of their right hip. DON stated the hospital will keep resident for 3-4 additional days before sending them to a skilled nursing. Resident was receiving physical/occupational therapy before the fall and moved in from a skilled nursing facility. Resident (R5) was observed to be in (R1's) room on March 18, 2025, (6:00 pm) by staff after hearing (R1) screaming. Staff was able to redirect (R5) from (R1's) room and there were no injuries observed. Both residents are being monitored for behaviors. (R1) didn't remember the incident and (R5) is currently non-verbal and taking antibiotics for a Urinary Tract Infection, which could have caused the confusion. 809C-1.. Resident (R6) was interviewed by LPA and the Ombudsman. Resident was observed to be resting in their room at the time of the discussion. Resident expressed concern about their medical group not addressing the reason for the recent trip to the emergency room on March 24, 2025. Resident confirmed she is receiving showers at least twice weekly, and staff is assisting with applying lotion for their skin condition. The DON confirmed that (R6) was prescribed a 10-day oral antibiotic and a topical creme following yesterday's visit to the emergency room. It appears the facility followed its protocols in sending all residents out for further medical evaluations. LPA requested updated care plans for residents (R2) and (R5) and hospital discharge paperwork for the last several hospital visits for (R6). There are no citations issued in this report. Exit interview. Copy of report to be emailed following today's inspection.the state’s words, verbatim · CDSS document, Mar 25, 2025

Allegation investigated: Resident was left on floor for an extended period of time. Staff did not report change of condition. Staff left residents in soiled diapers for an extended period of time. Resident is not receiving showers as scheduled.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver investigative findings to a complaint received on 11/12/24. LPA met with Danny Torgersen, Administrator, and Karen Padilla, Director of Nursing, and stated the reason for the inspection. During the course of the investigation, LPA interviewed the Administrator, Director of Nursing, Business Office Director, (3) staff, resident (R1) and a family member of (R1). LPA also reviewed documentation relating to (R1), including their physician's reports, appraisal/care plans, narrative charting notes, (2) incident reports (LIC624), shower schedules for months September- November 2024 and the Alarm Reset Report for 11/10/24 from 1200 hours through 23:59 hours. The results of the investigation are as follows: (R1) moved to the community and has resided on the Assisted Living side since moving in on 12/27/23. (R1's) physician's report (dated 10/16/24) notes resident has a diagnosis of Dementia with agitation and is taking medications, Melatonin 3mg and Olanzapine 2.5 mg, to assist with related behaviors. (R1) has a secondary diagnosis of Type 2 Diabetes Mellitus and takes medications for it. *cont on 9099C-1.. Unsubstantiated 9099C-1.. Per the physician's report,(R1) can be confused/disoriented, exhibit inappropriate behavior, including sundowning but is able to communicate needs and follow instructions. Allegation: Resident was left on floor for an extended period of time. The allegation states on the evening of 11/10/24 (R1) had a fall in their apartment and waited an hour and a half for staff to assist, after pressing their pendant. (R1) then called their family member, and they were on and off the phone while (R1) was on the floor. The facility finally responded but it was a caregiver that (R1) does not like so they refused care until a Med-Tech came to help resident off the floor. Staff (S1) confirmed she worked on the “pm” shift (2:00 pm- 10:30 pm) on Sunday, 11/10/24, and stated after dinner, she "moved (R1) from the dining room as they were being very verbal, cussing at me", and took (R1) to their room and offered them water. (R1) refused, was mad and then locked their door. (S1) returned to (R1's) room 15-20 minutes later, around 7:10-7:12 pm, and asked (R1) if they were okay and offered their scheduled dose of insulin, which (R1) said "No" to. (S1) stated that around shortly afterwards, she got a call on the house phone from (R1's) family member that (R1)was on the floor in her room. (S1) stated she checked on (R1) again around 7:20-7:30 pm, and "saw them on the floor". (S1) stated (R1) fell as they tried to transfer them self from their wheelchair to their bed and fell, and she and two other staff, (S4) and (S2), assisted her. (S1) asserted that "it was 10-15 minutes maximum that she was on the floor", and (R1) will "regularly push the call button if they are upset" and doesn't hesitate. A second staff (S2) confirmed he was working on the "pm" shift on Sunday, 11/10/24, when resident (R1) was found on the floor. (R1) commented "(R1) doesn't like men to help her, and I think Med-Tech, (S1), called me to help pick (R1) up, and we went to her room. (S2) confirmed that he, (S1) and another caregiver, female, assisted (R1) to get up from the floor. (S2)stated staff "do rounds, I have no idea how long they were on the floor, but it was not (3) hours, “adding, "I think they pressed their pendant" which goes to all staff's pagers. A third staff (S3) stated on 11/19/24 that she works "pm" shift but did not work on 11/10/24. (S3) explained that around 7:30/8:00 pm, caregivers will begin to put residents to bed, and staff will assist (R1) in the bathroom, change them into their pajamas, take off their dentures, comb their hair and put them to bed. (S3) stated staff will check on (R1) and all other residents again from 8:30/9:00 pm to make sure residents are in bed before 10:00 pm, when the shift change occurs. *cont on 9099C-2.. 9099C-2... On 11/19/24, resident (R1) stated to LPA that "probably fell" when asked if they fell on 11/10/24. (R1) commented that they "sometimes need help" transferring from their wheelchair to their bed and will use the mobility pole also, pointing to it. (R1) indicated they were certain they called for staff, using their pendant, after they fell and waited for 1.5 hours until "finally 3-4 people arrived late at night". (R1) indicated that all the staff who helped here were female. Charting notes document that on 11/9/24 (9:59 pm) (R1) “slipped out of their chair in their bedroom” and was not observed to have any bruising or injuries following. Charting notes indicate that on 11/11/24 (12:40 pm) that a Med-Tech notified resident’s POA that (R1) had an unwitnessed fall at 10:30 pm (11/10/24). The LIC624 submitted for the fall on 11/10/24 (10:00 pm), indicates (R1) was found by care staff on the floor in front of their wheelchair. This report, completed by a Med-Tech, states (R1) stated they slipped off their wheelchair and on to their bottom and did not hit their head and (R1) was reminded on how to use the call button/pendant and staff will continue to monitor. A family member of (R1) stated that (R1) fell on the evening of 11/10/24 (Sunday) around 8:45 pm- 9:00 pm., and (R1) waited 1.5 hours for help, after she fell. The family member indicated (R1) fell when trying to transfer from their wheel chair to their bed, and (R1) was waiting for staff to assist for (3) hours before she fell, and was pressing her pendant. LPA was informed that any caller can call the main number and request to have the call routed to the Med-Tech's cell phone and the resident's room will be identified. The Alarm Reset Report was reviewed for 11/10/24, from 1200 hours through 23:59 hours. The report shows (R1’s) call button was initially pressed at 1:28 pm (staff responded/re-set the button at 2:14 pm -45 mins later), and (R1’s) call button was pressed a second time at 2:15 pm (staff responded/re-set the button at 2:21 pm- 6 mins). The report does not reflect any other times on 11/10/24 when (R1’s) call button was activated and shows multiple times when other resident’s call buttons were pressed, with no significant time gaps, in between each call. The report shows the shortest time response was (1) minute and the longest time response was (45) minutes. Based on information obtained, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint 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. *cont on 9099C-3.. 9099C-3.. Allegation: Staff did not report change of condition. The allegation states that resident’s family member was not informed of (R1) having a change in behavior, specifically becoming more aggressive verbally and using inappropriate language towards care staff, until the facility sent (R1) out to the hospital in the beginning of October 2024. Charting notes were reviewed from 4/19/24 through 12/29/24 . The first time behavior was documented as an issue was on 5/8/24, when (R1) refused to allow staff to take their blood pressure. Notes entered on 9/4/24 and 9/8/24 relate to the monitoring of Farxiga for Type 2 Diabetes. The next entry, on 10/6/24 (4:25 am) , document that (R1) was placed on alert charting after returning from the hospital and being diagnosed with a UTI and starting an antibiotic. POA was again notified. Notes entered on 10/10/24 (5:17 pm) say (R1) was sent out again due to UTI symptoms and complaining of neck pain. Resident returned on 10/11/24 (2:00 am) with two new medications- Lidocaine and Olanzapine (Zyprexa 2.5 mg) and staff continued to monitor. Notes made on 10/18/24 (3:49 pm) document (R1) was placed on alert charting to monitor the effects of Olanzapine, which was prescribed to help with agitation and behaviors related to Dementia. Care staff (S1) confirmed that (R1) resided at the community when she started and she didn't observe any behaviors with (R1) until around October 2024, commenting she is not sure "what prompted it". (S1) stated (R1’s) behavioral problems started in October, 2024, when (R1) began using derogatory comments towards some of the staff. (R1's) care plan, dated 11/30/23 was reviewed. On 11/2/24, (R1's) care plan was updated to include a change in (R1's) mental condition, specifically that (R1) has behaviors, will start screaming and fight with any resident/staff, and will call out names or say inappropriate words to both staff/residents. Based on information obtained, LPA finds allegation to be (US) Unsubstantiated - A finding that the complaint 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. *cont on 9099C-4.. 9099C-4... Allegation: Staff left residents in soiled diapers for an extended period of time. The allegation states (R1) wears a brief but can still use the toilet, however staff rarely get to (R1) in time so (R1) has to use their brief and sits in soiled briefs for an extended period of time because no staff will assist. (S1) explained that (R1) began using inappropriate language towards staff in October (2024), and (R1's) family member will randomly call and say "(R1) is complaining of not being changed" and will request that a female caregiver be provided. (S1) stated that there are (3) male caregivers currently and (1) works on the NOC shift and (2) work on the "pm" shift. (S1) was asked if staff have ever left (R1) in soiled diapers for an extended period of time. (S1) stated "(R1) will usually tell us 50/50 when they have to use the bathroom". (S1) explained that dinner starts at 4:30 pm and (R1) "is usually done by 5:15 pm" and staff will take (R1) from the dining room to the front door area as (R1) "likes to see outside the front door". (S1) indicated she "has never seen (R1) soiled with or smell of BM" but (R1) has been soiled with urine before and (R1) will tell staff when they are. A second staff (S2) indicated he didn’t have any information since men can’t provide incontinent care to (R1). A third staff (S3) stated that around 7:30/8:00 pm, caregivers will begin to put residents to bed, and staff will assist (R1) in the bathroom. LPA asked (R1) if she is able to get to the bathroom independently- ? (R1) replied "sometimes I can get on the toilet". Both the initial care plan (dated 11/30/23) and the updated care plan (dated 11/2/24) note (R1)requires one-person assistance due to being incontinent. Both physician's reports (12/11/23) and (10/16/24) note (R1) is incontinent (x2). Based on information obtained, LPA finds allegation to be (US) Unsubstantiated - A finding that the complaint 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. 9099C-5.. Allegation: Resident is not receiving showers as scheduled. The allegation states (R1) has not received a shower for 2+ days and the shower chair has been broken for at least 2 days. One staff (S1) who works on the “pm” shift stated she is "not sure if (R1) receives showers on the "am" or "pm" shift, but (R1) never stinks", commenting "maybe (R1) is "am" because (R1) has their bed on the "A" side of the room. (S1) stated she puts (R1) in pajamas at night and resident is clean. A second staff (S2) indicated he doesn’t know about showers as the female caregivers give (R1) a shower. On 11/19/24, a third staff (S3) confirmed that (R1) hasn't missed any showers and will regularly accept them, confirming the last shower was the day before yesterday on Sunday. (S3) explained sometimes the "pilot light" goes out and there is "no hot water for a while". (S3) explained the light went out recently and staff are now checking for hot water before getting the resident undressed. (S3) confirmed staff will document when showers are given, (R1) doesn't typically refuse, and confirmed caregivers will rotate halls so they work with different residents. The Administrator stated the water heater was recently replaced in January 2025 as the prior water water (tankless) had factory defects. LPA reviewed shower schedules for September -November 2024 (week ending 11/18/24). (R1) is scheduled for a shower twice weekly, on Mondays and Thursdays. The schedules showed staff initialed that (R1) received a shower on the following days: Monday, 9/2/24, 9/9/24, 9/16/24, 9/23/24 and 9/30/24 and on Thursday, 9/5/24, 9/12/24, 9/19/24 and 9/26/24. Monday: 10/7/24, 10/21/24 and 10/28/24 and on Thursday: 10/3/24, 10/10/24, 10/24/24 and on 10/31/24. Staff notes indicate (R1) was “out” of the facility on Monday, 10/14/24 and on Thursday, 10/17/24. Monday, 11/4/24 and 11/11/24 and on Thursday, 11/7/24 and 11/14/24. The Director Of Nursing stated (R1) has a new shower chair and never missed a shower. On 11/19/24, (S3) looked in the bathroom and confirmed with LPA the shower chair was not currently there, commenting it is typical for staff to borrow chairs, and (R1's) roommate's daughter just brought a new chair in that has wheels and stated (R1) had a shower chair without any wheels before. Based on information obtained, LPA finds allegation to be (US) Unsubstantiated - A finding that the complaint 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. Copy of report provided. 9099A-C.1...(R1's) family member stated the care home wants (R1) to move on 11/21/24 due to a "change in behavior", specifically (R1) is being more verbally aggressive, commenting she didn't know about the aggression until they sent (R1) to the the hospital on 10/5/24, for an apparent UTI. The family member stated she did not receive a written notice as it was sent to her local address, which she has not been to so since injuring her foot a few weeks ago. The family member stated she informed the Administrator and he then emailed her the notice on 11/11/24. Emails were not provided to the Department between the facility Administrator and the responsible person, as requested. There were several notes made in (R1's) file for October regarding behavior changes and new medications. Charting notes say resident returned from ER on 10/6/24 and was diagnosed with UTI. Family notified. (R1) sent out again to ER on 10/11/24 (5:00 pm) UTI symptoms and neck pain. POA notified. Notes made on 10/6/24 indicate (R1) was placed on alert charting after returning from the hospital on 10/6/24, being diagnosed with a UTI and began an antibiotic. POA was notified. Notes entered on 10/10/24 (5:17 pm) say (R1) was sent out again due to UTI symptoms and complaining of neck pain. Resident returned on 10/11/24 (1:40 am) with two new medications- Lidocaine and Olanzapine (Zyprexa 2.5 mg) and staff continued to monitor. Notes made on 10/18/24 document (R1) was placed on alert charting to monitor the effects of Olanzapine- prescribed to help with agitation and behaviors related to Dementia. Additional charting notes document (R1) continued to have behavioral expressions towards staff on 11/26/24, 11/28/24, 12/3/24, 12/4/24, 12/5/24 (4:12 pm, 4:30 pm and 8:30 pm). LPA reviewed the 30-day notice, dated 10/17/24, issued to (R1) and their responsible person. Based on Regulation 87224/Eviction, the letter contained a valid reason- behavioral care need not previously identified- and all other required elements were contained in the letter. On 11/19/24, the Administrator stated he is not enforcing R1')'s eviction to be moved out by 11/21/24. (R1) has remained living at the community. The Administrator confirmed on 2/10/25 that the eviction notice was “rescinded”, due to (R1’s) behavior improving some; however, a letter to that effect was not issued. Based on information obtained,LPA finds the allegation to be UNFOUNDED-A finding of 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, Feb 11, 2025 · control 59-AS-20241112093306

Allegation investigated: Due to staff neglect, resident received multiple pressure injuries

On 2/4/25, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Daniel Torgerson. LPA conducted facility and home health records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. R1 was admitted on 9/12/24 with history of CVA, heart failure and dysphagia. At admission, R1 also had redness on their heal and coccyx. Home Health was provided throughout R1's stay. 10/3/24, R1 had a new stroke which contributed to further decline. Throughout R1's stay, records and interviews found that R1's care plan was followed as directed by home health and resident appraisals. R1 was sent to the hospital on 12/2/24 for change of condition and passed away in the hospital on 12/4/24. report continued... Unsubstantiated Records reviews and interviews found no additional evidence to support that R1's pre-existing conditions were made worse due to neglect. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint 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 with administrator and report provided.the state’s words, verbatim · CDSS document, Feb 4, 2025 · control 59-AS-20241202113451

Allegation investigated: Facility withheld residents medications upon move out.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to commence and conclude a complaint investigation. LPA met with Danny Torgersen, Administrator, and Karen Padilla, Director of Nursing, and stated the reason for the inspection. During today's inspection, LPA interviewed the Administrator, Director of Nursing (DON) and (1) Med-Tech staff who conducted the discharge with prior resident (R1) on 12/30/24. Documentation related to (R1) was reviewed including the physician's report, charting notes, physician's orders, December Medication Administration Record (MAR), and medications released upon discharge. The results of the investigation are as follows: cont on 9099C-1.. Unfounded 9099C-1.. Allegation: Facility withheld residents medications upon move out. The allegation states the facility would not allow resident (R1) to take all of their medications or the medication orders to the new facility. Both the Administrator and the Director of Nursing (DON) stated that prior resident (R1) did not have a diagnosis of Dementia but exhibited behaviors for the duration of the time they resided at the facility. Both managers confirmed that (R1) was taking several psychotic medications since moving in on/around end of June 2024, and the December MAR shows an effective date of 6/21/24 for these (3) medications. LPA reviewed Physician's Orders, updated on 12/24/24, to note that Buspirone 10mg, Hydroxyzine HCL 50 mg tablets, and Trazadone 100mg were discontinued that day. The Medication Administration Record (MAR) for December 2024 reflects these (3) medications being discontinued effective 12/28/24 on the MAR, the day the facility entered the changes in the system. Charting notes state that (R1) was placed on alert charting for any adverse reactions or unusual responses to the (4) new supplements prescribed on 12/24/24- Fish Oil 1200MG, Preservision Areds, Probiotic Blend and D-Mannose 500MG. Also discontinued were (9) other medications to be taken as needed for pain, constipation, cough, nausea and dry eye. The Director of Nursing stated the medication orders were updated by (R1's) regular primary care physician, whom they saw regularly. These (9) medications and all others that were not discontinued on 12/24/24, were discontinued effective 12/30/24, on the MAR, the day when (R1) moved from the facility. Documentation was reviewed showing (24) medications were given to (R1) and their responsible person on 12/30/24, when moving from the facility. The Med-Tech staff confirmed that her signature and (R1's) family member's signature is listed on the documentation and that both (R1) and their family member were present when she returned (R1's) unused medications from the med cart and overflow, and there was no disagreement about the medications being returned. The MAR shows (21) medications were administered or scheduled to be administered through the evening of 12/30/24. (R1) moved out at approximately 5:00 pm. The discrepancy is due to (R1) having (2) bottles or bubble packs of fish oil and D-Mannose. The DON confirmed that on 12/31/24, (1) additional medication, Lidocaine 5% was given to the facility nurse where (R1) moved to, as this medication was inadvertently not returned the day before at move out. *cont on 9099C-2.. 9099C-2... The DON stated she indicated to the nurse that any medications that were not returned by 12/31/24 was due to the physician discontinuing them on 12/24/24, and the nurse stated she would follow up with contacting (R1's) doctor's office due to behaviors (R1) is showing at the new facility. Based on information obtained, the facility followed the physician's orders and stopped giving all medication that was discontinued on 12/24/24 upon receiving the updated orders. The facility will ensure any discontinued medications will be destroyed promptly per facility protocols, and by (2) staff members. Based on information obtained, LPA finds the 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. A copy of the report provided.the state’s words, verbatim · CDSS document, Jan 3, 2025 · control 59-AS-20241231154627

Allegation investigated: Unlawful eviction.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open and close a complaint investigation. LPA met with Daniel Torgersen, Co-Administrator, and Karen Padilla, Director of Nursing, and explained the purpose of the inspection. The results of the investigation are as follows: The Department received a copy of each 30-day eviction notice issued to (5) different residents on/around 10/1/24. The notices were provided to the Department timely and included all of the required information, per Regulation 87224. All notices were issued due to non-payment of rent. The Co-Administrator stated on 10/15/24 that (3) of the (5) residents have now made payment towards the unpaid rent balances, and the 30-day notices have been rescinded. There are (2) residents who are currently working with the Social Services Director to arrange for payment so those notices may be rescinded also. The Co-Administrator confirmed that the facility has always been issuing monthly rent invoices to residents and their responsible person, and that families have been aware of the outstanding rent balances. Based on information obtained, LPA finds the 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. Unfoundedthe state’s words, verbatim · CDSS document, Oct 15, 2024 · control 59-AS-20241007121222

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Sabrina Calzada conducted a scheduled Pre-Licensing Inspection on 9/18/24 at 11:00 am. LPA met with Daniel Torgersen, Co-Administrator, Karen Padilla, Director of Nursing. Caleb Summerhays, Administrator, was present from 12:00 -2:00 pm. The reason for the pre-licensing is due to a change in ownership. There are (74) residents currently residing at the facility, (15) of whom are under hospice care. The facility is currently licensed for (78) bedridden residents, has a hospice waiver for (20) residents, and has separate Assisted Living and Memory Care units. All resident areas are on the first floor. The second floor is used for office and storage space. LPA and Administrator toured the interior of the facility, including the common areas in both the Assisted Living and Memory Care units, the main kitchen, resident rooms, activity rooms, main laundry and outside patios. The facility was observed to be clean, in good repair and to have sufficient furniture and lighting throughout. There are (6) delayed egress doors throughout the facility with signs posted. Residents have a call button to use that is monitored on staff pagers and at the front desk. There are complete first aid kits in the medication rooms and the fire extinguishers were serviced on 5/28/24. Blankets/linens/supplies are kept in the laundry room. The hot water temperature is set at 120*F and measured within the required range of 105-120* in a resident bathroom and a main bathroom. Inside temperature measured 74*F. There is sufficient 7+day non-perishable and 2+day perishable supply of food, including fresh produce, and the freezer/refrigerator temperatures are set at required temperatures. Daily logs are maintained to ensure temperature controls are in compliance. The Ice machine is cleaned regularly. Activities are posted within each A/L and M/C unit. Vehicle maintenance records were reviewed along with resident and staff binders. All records were organized and contained current paperwork. Required posting are visible in the common area. Comp III was conducted during today's inspection. Pre-licensing is complete and this facility has no deficiencies. LPA to notify analyst in application unit. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 18, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 78 Census (if any clients in care): 51 Interview Method: Telephone interview On 5/23/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, May 23, 2024