Oakwood Village

Type of visit: Case Management - Other

Licensing Program Analyst, Melissa Parks arrived on Friday April 17, 2026 for an unannounced inspection to follow up on a substantiated allegation of neglect, resulting from a complaint investigation. On December 3, 2024, the Department concluded a complaint investigation regarding the following allegation: Resident sustained unexplained fracture while in care. The licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87466 Observation of a resident. At the time of the complaint visit on December 3, 2024, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty was still being determined and might be assessed, based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code §15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation. This is evidenced by facility staff not seeking timely medical attention for a resident (R1) in care, which was a substantial contributing factor that resulted in R1’s increased pain and confusion following an unwitnessed fall. Today, April 17, 2026, the Department is issuing a civil penalty per Health and Safety Code § 1569.49(f) in the amount of $10,000 for a violation that the Department constitutes as serious bodily injury. However, since an immediate civil penalty of $500 was previously issued on December 3, 2024, the amount of the civil penalty issued today is $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Patty Uclaray's name and signature on this report acknowledges receipt of the appeal rights, found on page two of the LIC 421D.the state’s words, verbatim · CDSS document, Apr 17, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced and met with Executive Director Patty Uclaray and Resident Care Director Malina Meador to follow up on an SOC341 and incident report submitted by the facility on 03/21/2026. LPA reviewed pertinent documentation, toured facility and conducted interviews pertinent to the investigation. At this time, no deficiencies cited. Exit interview conducted. Copy of report given to facility.the state’s words, verbatim · CDSS document, Apr 9, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced and met with Executive Director Patty Uclaray to conduct an annual inspection utilizing the inspection tool. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed resident rooms, common area bathrooms, common areas, kitchen, activities room, and perimeter of care facility. LPA observed rooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained. LPA checked the kitchen area for the ability to prepare and store food. Care facility has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are operational in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed eight (8) resident files, three (3) staff files and resident medications. Facility has a current copy of certificate of liability insurance and LPA requested a copy. As a result of this visit, no deficiencies were cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted with Administrator.the state’s words, verbatim · CDSS document, Feb 5, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced to conduct a case management visit regarding an incident report received on 12/15/2025 regarding a medication error made. LPA reviewed medications of residents and discussed with Executive Director Patty Uclaray the changes in procedures for medication passing during visit. On 12/11/2025, Resident R1 was given the wrong medication during morning medication pass by Staff member S1. Staff immediately called poison control and monitored R1 closely. Staff contacted R1’s responsible party who declined to have R1 sent to emergency room for evaluation. No negative outcome noted. Although a medication error was made, it appears that the staff reacted immediately to follow up and ensure the resident's safety. Staff has been reassigned permanently. As a result of this visit, a deficiency is being cited on 9099- D page. As a result of medication error, a civil penalty is being assessed in the amount of $250.00. Appeal rights given. Exit interview conducted.the state’s words, verbatim · CDSS document, Dec 16, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 23, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This was not met by evidenced by: Resident R1 was given the incorrect medication on 12/11/2025 by Staff S1.the state’s words, verbatim · CDSS document, Dec 16, 2025

Plan of correction: Facility has pulled S1 permanently from passing medications. Facility has changed procedures to have med tech take med cart to each room to hand out medications to avoid additional errors.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced to conduct a case management visit regarding two separate incident reports received on 11/21/2025 and 11/14/2025 regarding medication errors made. In both incidents which occurred on 11/20/2025 for resident R1 and 11/11/2025 for resident R2, R1 and R2 were given the wrong medication. Staff acted quickly, calling poison control and emergency services. Both residents involved had no ill effects from the error. Although a medication error was made, it appears that the both staff reacted immediately to follow up and ensure the resident's safety. Both staff have been reassigned and given re-training on medications. As a result of this visit, a deficiency is being cited on 9099- D page. Appeal rights given. Exit interview conducted.the state’s words, verbatim · CDSS document, Nov 25, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 2, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This was not met by evidenced by: 11/11/2025 and 11/20/2025 Residents R1 and R2 were given the wrong medications by med techs S1 and S2.the state’s words, verbatim · CDSS document, Nov 25, 2025

Plan of correction: Facility has conducted additional trainings for staff S1 and S2. Facility also will continue to conduct yearly medication training for all staff.

Type of visit: Office

Licensing Program Analyst (LPA) Cassandra Mikkelson and Licensing Program Manager (LPM) Laura Munoz conducted an informal meeting with Oakwood Village (Executive Director Patty Uclaray and Operating Officer Mary Roberts) in regards to the substantiated complaint on 06/05/2024. LPM and LPA discussed the importance of fall safety and assessing fall risks with Patty and Mary. Patty and Mary have implemented trainings for staff, both videos and hands on training and also the Care Life Monitoring system. Staff are trained to be comfortable calling for emergency services for any fall. Facility is in good compliance, no citations were issued during today's meeting. LPA sent a copy to Executive Director Patty for signature as meeting was held online.the state’s words, verbatim · CDSS document, Oct 22, 2025

Allegation investigated: Staff are not properly addressing pest infestation in the facility Staff are not practicing proper hand washing procedures Staff do not ensure kitchen appliances are in proper working order Staff are not meeting residents dietary needs Facility kitchen is in disrepair

LPA Tryon visited the facility on 6/19/2025 to continue work on the complaint. LPA met with ED Patty Uclaray. LPA toured the assisted living dining room and memory care dining room, viewed the noon meal, watched servers working, observed residents eating and spoke briefly with several residents, LPA also interviewed 3 kitchen staff. Over the course of visits. LPA has toured the dining areas, kitchen, dishwashing area, food storage, cooler/freezer, separate Ice cream freezer, staff dining area, outside hose area where rubber mats are washed down, spoken with ED, Director of Dining Services, 3 kitchen staff, and resdidents, reviewed documents. Regarding the allegation that staff are not properly addressing pest infestation, LPA spoke with ED, Dining Director and 3 kitchen staff. No one has witnessed bugs, rodents or pests in kitchen/food storage or dining areas. LPA toured these areas and did not see any pests, no "droppings" or other evidence of pests. The facility contracts with a pest control service who treat the grounds/facility. LPA also obtained Invoices for twice a month service from the pest control company. The facility is clearly addressing the issue, and staff have not noted pests present. Allegation is unfounded. Unfounded Regarding allegation that Staff are not practicing proper hand washing procedures, in interviewing kitchen staff and Director of Dining Services. It appears that staff are diligent about hand washing at appropriate times. Allegation is unfounded. Regarding the allegation that Staff do not ensure kitchen appliances are in proper working order, LPA has toured the kitchen, interviewed staff, ED and Director of Dining Services. LPA learned there are currently no broken or non-working appliances. LPA learned that in general if something breaks or stops working, staff take appropriate action to have it repaired or replaced. LPA learned that a freezer was broken a few weeks ago, but staff quickly moved the frozen food to a freezer in another building, then quickly had it repaired. Food did not have an opportunity to thaw. No thawed or spoiled food has been served. Allegation is unfounded, Regarding allegation that Staff are not meeting residents dietary needs, LPA interviewed ED, Director of Dining Services, staff, observed meals and checked in briefly with residents. The facility has lists of residents with special dietary needs/requirements in the kitchen so that needs are met. Meals appear appetizing and nutritious. Residents appear to enjoy the food overall. Allegation is unfounded. Regarding the allegation that Facility kitchen is in disrepair, LPA toured the kitchen, spoke with staff and Director of Dining Services. LPA saw no evidence of any kind of leaks or large amounts of water in any area of the kitchen or dining areas, no stains to indicate leaks etc There was a small amount of water near dishwasher from a little spilled water off dishes, but there were rubber mats for safety. LPA questioned staff regarding method for cleaning rubber mats, and they all stated this is done by taking them outside and using a hose provided for that purpose; no one saw mats washed in the dishwasher as alleged; and stated they would not fit into the dishwasher as the mats are too large. Allegation is unfounded. A finding that an allegation is UNFOUNDED means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited at this visit. Exit interview was conducted.the state’s words, verbatim · CDSS document, Jun 19, 2025 · control 59-AS-20250604145853

Type of visit: Case Management - Incident

On 6/19/2025 LPA Tryon did a Case Management Visit to the facility to look into an Incident Report from incident on June 14, 2025. SIR reported that a resident had left the facility, went down the street and fell. A bystander called 911 and resident was taken to the hospital. On this date, LPA met with Administrator Patty Uclaray at the facility. Ms. Uclaray told LPA the following: Resident R1 had no history ever of trying to leave the facility. As a matter of fact, R1 had until very recently had a car and drove. R1 has a crafting type of hobby that R1 is very involved with, and has tools to do that. R1 does NOT live in memory care, but in assisted living. Until just about a week before the incident, R1's Physician Report stated that R1 did not need supervision to leave the facility. A Physician Report done on 6/6/25 stated supervision was necessary to leave the facility. However, no attempts had ever been made; and R1 never had to be watched in that way. In the past few weeks, R1 appeared to be having some memory-type issues, that is why the updated physician visit/report was sought out. R1 had some major upsetting life events recently, that may have contributed to changes. On 6/14 resident had left without telling anyone. It was subsequently learned that R1 was going to a local store to make a purchase, so thought walking was okay. It appears R1 intended to shop and return to the facility, not to stay away. R1 did apparently fall and get a bump, but it was not a serious injury, and R1 was cleared by the ER to return. However, while at the hospital other issues were found, and R1 was kept for observation/tests. Several major diagnoses were made in the hospital this week, some of which may contribute to temporary memory issues. Administrator is visiting R1 at the hospital tomorrow to do an assessment as to whether return to Oakwood Village is appropriate; or if a more appropriate facility will need to be found. At this point, the facility did not have awareness that R1 might try to exit independently. Facility appears to have reacted appropriately once aware of the issues and is following up appropriately. No deficiency is cited today; LPA will keep informed of progress.the state’s words, verbatim · CDSS document, Jun 19, 2025

Type of visit: Required - 1 Year

On 3/26/2025 LPA Tryon visited the facility to conduct a required annual visit. LPA met with Executive Director Patty Uclaray. The facility currently has 58 residents. LPA toured the facility with Ms. Uclaray including common areas, resident rooms, bathrooms, kitchen, dining area, food storage, hallways, medication rooms, storage for potentially hazardous items and materials, laundry room. The facility is clean and well-furnished, resident rooms were clean and had appropriate furnishings. Food supplies appeared to be well-stocked to meet the requirement of 2 days perishable and 7 days non-perishable. Food was stored appropriately to maintain freshness. Lunch appeared appealing and appetizing. A new dining management company took over the kitchen in February and is running all the kitchen operations. It is going well so far. Residents have spoken up and said the menus are too "fancy", but the company is responding and making changes. There is a monthly dining committee that meets regarding these issues. Medications are centrally stored and locked. Facility keeps centrally stored logs. Logs are on computer; and back-up binders. Controlled substances are double-locked in the medication carts. Chemical storage was viewed, cleaning chemicals are stored in a locked metal cabinet. Hot water is within appropriate temperature range. The building has a fire alarm/sprinkler system that is checked regularly. Fire extinguishers present and charged. LPA reviewed the CARE Tool with Administrators. LPA interviewed 1 staff and 1 resident, reviewed 5 resident charts and 6 staff charts. LPA requested copies of current liability insurance proof, administrator certificates. At this time the facility appears to be in substantial compliance with the regulations. No deficiencies cited.the state’s words, verbatim · CDSS document, Mar 26, 2025

Type of visit: Case Management - Incident

On 3/19/2025 LPA Tryon visited the facility to follow up on an incident report dated 3/14/2025. LPA met wtih Destiny Moore. The report stated that a resident had gone outside in the evening to smoke with a friend from outside the facility. The resident came back in a short time later, saying that resident had been attacked by a man and woman outside on the sidewalk, the resident said the strangers had hit and scratched resident. The facility called the police, who responded, spoke with resident and made a report. Videos from the facility were reviewed and nothing was seen. The cameras do not have a view of the position resident was in at the time. Resident could not describe the strangers. Police said at this point there is really nothing they can do, as they have no way to identify them. Facility has asked the resident to not go outside and prop the door open to smoke. If resident goes out, the staff will need to be called or doorbell rung to get back in, for the safety of all the other residents. Resident was offered medical attention and declined. Resident is doing okay at this time. It appears the facility reacted appropriately in the situation. Exit interview conducted.the state’s words, verbatim · CDSS document, Mar 19, 2025

Allegation investigated: Staff did not follow residents care plan Staff did not ensure the bed/chair alarms were in working order Staff did not ensure residents personal hygine needs were met

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Administrator Patty Uclaray to deliver findings for the above complaint allegations. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: ***Report continued on 9099-C*** Unsubstantiated Interviews with Residents R1, R2, R3, and R4 indicated that each were happy with the care they have been receiving at the facility from all care staff. R1, R2, R3, and R4 all use call buttons either worn as a bracelet or a necklace. Each indicated that when they push their call button for help, care staff arrive promptly to assist. R2, R3 and R4 stated that they receive help with showers each week. R2, R3 and R4 have not had any issues receiving showers by staff or changing shower days based on what is convenient for them. R1 is able to shower independently but feels comfortable asking for help from staff when needed. Interview with Administrator Patty Uclaray indicated that residents must have a signed consent form that authorizes the use of call buttons or bed/chair alarms as it is not a requirement by the facility that each resident wear a call button. Administrator Uclaray stated that the facility is actively hiring more staff to decrease call button response times by staff and improve overall resident care and supervision. Administrator stated that each resident has their own care plan which coincides with their current LIC602/ physician’s report and is updated yearly or when a resident had a change in condition. During the investigation, LPA toured the facility with Administrator Patty Uclaray. LPA observed resident rooms and hallways to be in clean and sanitary condition with no odors. LPA did not observe any residents to be in poor hygiene. Through interviews conducted and documents reviewed, LPA determined that staff are assisting residents meet their hygiene needs. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. Findings 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 was conducted with Patty Uclaray. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Feb 27, 2025 · control 59-AS-20250207144045

Allegation investigated: Resident in care had access to centrally stored medications

On 12/12/2024 LPA Tryon visited the facility to complete the complaint. On this date LPA met and spoke with resident involved. LPA has spoken with resident, Executive Director and staff. LPA learned that recently Resident R1 was discovered to have a bottle of Tylenol in room. LPA learned that R1 had purchased the medication, not being aware that any medications must be centrally logged, stored and locked in the medication room by staff, and that a doctor prescription is needed. When R1 became aware of this, the medication was given to staff, stored and locked, and a precription was obtained for the medication from the physician. Staff are now handling the medication and R1 receives it as needed. Since the facility was not previously made aware of the medication being present; it was turned over immediately, staff cannot violate resident rights by randomly searching through resident apartment or belongings without resident permission; and staff had no reason to suspect anything was there or to even ask permission to look, the allegation is 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. Unfoundedthe state’s words, verbatim · CDSS document, Dec 12, 2024 · control 59-AS-20241206144513

Allegation investigated: Resident sustained unexplained fracture while in care.

Licensing Program Analyst Todd Tryon visited the facility unannounced on 12/3/24 to deliver the findings of the investigation completed by the Department. The Department concluded that on June 1, 2024, at approximately 9:30 PM, Med-Tech S2 completed their shift after ensuring R1’s bed alarm was activated, a standard procedure given R1’s fall risk. At 11:30 PM, S1 discovered R1 on the floor during a routine room check but did not recall hearing the bed alarm. S1, who lacks medical training, assisted R1 to bed without informing any Med-Tech, administrative personnel, or family, as required by facility policy. According to the administrator, any unwitnessed fall must result in an immediate call to AMR, and notifications to Med-Tech staff, administration, and family members. R1’s family had, in coordination with the facility, implemented a care plan involving a bed alarm to prevent falls. However, on June 1, 2024, this bed alarm was apparently not working or was not turned on, potentially leading to R1’s undetected attempt to leave the bed, resulting in the fall. The findings show that staff failed to verify the alarm was activated as required by the care plan, resulting in R1’s injury. Based on interviews, Med-Tech S2 confirmed the alarm was turned on at shift end. Based on S1’s interview, S1 indicated that the bed alarm was not functioning as intended and that no medical Substantiated evaluation followed the incident. Based on an interview with S1, the caregiver involved, S1 confirmed awareness of the fall policy during their interview but did not act in accordance with it. Based on documentation reviewed, it showed that R1 was identified as a high fall risk. R1’s care plan, a joint agreement between R1’s family and the facility, included the consistent use of a bed alarm to prevent unassisted movement that could lead to falls. S2 confirmed activating the alarm before their shift ended at 9:30 PM. However, at 11:30 PM, S1 found R1 on the floor with no alarm sounding, suggesting the alarm was either turned off or malfunctioning at the time of the fall. Failure to ensure the alarm was functioning compromised R1’s safety, as it prevented prompt staff response. Based on records reviewed, the facility protocol for unwitnessed falls and need for immediate notification. Care Plan Documentation: Care plan agreement between R1’s family and facility specified the use of alarms to mitigate R1’s fall risk. On June 1, 2024, at approximately 11:30 PM, R1 was found on the floor by S1, who assisted R1 back into bed without a medical evaluation or consultation with any staff members. S1 failed to report the incident as a fall due to personal judgment. On June 2, 2024, at approximately 6:30 AM, staff observed R1 exhibiting signs of pain during their morning routine and transfers. By 3:30 PM, after a noticeable decline in R1’s condition—symptoms including swelling of the left hip, pale skin, increased confusion, and a skin tear on the left elbow—R1 was transported to the hospital. R1 was sent to the hospital nine hours after pain was first reported. Medical evaluation at the hospital revealed a displaced comminuted basicervical femoral neck fracture and osteoarthritis of the hip. R1 passed away on June 16, 2024, with the primary cause of death identified as the femoral neck fracture and fall. Any report of pain following a potential fall should prompt immediate evaluation by Med-Tech staff, but R1 did not receive this evaluation. Staff interviews confirmed that R1’s condition worsened throughout the day, and only then was hospitalization sought. Based on records reviewed, R1’s fall (6/1/2024) to hospitalization (6/2/2024) document a gap in medical response. Medical Reports: X-rays from the hospital confirmed R1’s femoral neck fracture. Interviews: Staff accounts confirm R1 reported pain throughout the morning without escalation to Med-Tech or administration. Death Certificate: Cause of death includes factors directly related to the fall and delay in medical care. Facility Policy per administrator notes the facility policy mandates that any unwitnessed fall requires immediate medical assessment, which S1 did not pursue. The facility’s failure to properly train and instruct staff on reporting and responding to falls contributed to a delay in essential medical care for R1. Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency and civil penalty are being issued. Appeal rights provided, exit interview conducted. An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted.the state’s words, verbatim · CDSS document, Dec 3, 2024 · control 59-AS-20240605153211

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Dec 4, 2024

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. .. changes such as ... physical health cond. are observed...changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. Based on interviews conducted and documentation reviewed. this requirement is not met as evidenced by: It is the documented policy of the facility, that if a resident has an unwitnessed fall, staff is to immediately contact emergency services to evaluate the resident. The Dept. determined that the facility's policywas not followed.Staff assisted the resident back to bed without first notifying Med Tech, Admin. Personnel, or family, as required by facility policy. Records and interviews indicate Resident began to show signs of pain after approximately 7 hours after the fall, but medical attention was not sought until approximately 9 hours after the first symptoms of pain were noted.the state’s words, verbatim · CDSS document, Dec 3, 2024

Plan of correction: The facility will ensure that all care staff are properly trained on policy and procedure regarding falls and follow-up medical attention. Plan for training staff will be submitted to CCL by 12/4/2024.. The facility has already done training with care staff regarding falls and follow-up procedures and medical attention. Training was completed on POC complete.

Allegation investigated: Staff does not ensure sufficient activities are planned for memory care residents Staff does not ensure adequate quantity and quality of food is provided to memory care residents

On 12/3/2024 LPA Tryon visited the facility to complete the complaint. LPA met with Administrator Patty Uclaray. During the course of the complaint LPA has Toured the facility including Memory Care unit, main dining room and kitchen, Memory Care dining room, snack areas in both Assisted Living and Memory Care, spoke with Admiistrator, Culinary Director, interviewed 5 staff and 2 residents from the memory care unit, observed an activity in Memory Care which included an art activity and snacks with 10 residents; observed activity in the assisted living side. Regarding the allegation that staff does not ensure sufficient activities are planned for memory care residents, LPA has observed activities, spoken with Administrator, Activity Director, 5 staff and 2 residents. and reviewed printed activity schedules. LPA found ongoing mulitple activities are scheduled. Staff and residents state that activities are offered. They also state that some residents choose to not participate, or may participate for a time, then walk off to other areas, etc. Staff noted they cannot force people to participate in activities, but do offer the activities and try to encourage participation. LPA finds the allegation to be UNFOUNDED. Unfounded Regarding the allegation that Staff does not ensure adequate quantity and quality of food is provided to memory care residents: LPA interviewed the Administrator, Culinary Director, 5 staff and 2 residents, viewed meals and snacks stocked in "snack" areas; visited the kitchen and viewed food on hand, menus, etc. Staff related that they believe there is plenty of food for meals; in fact, there are often complaints that there is too much food for memory care residents and food may get wasted. There are always choices of food available, if a resident doesn't like the menu for a meal, they can ask for alternatives such as sandwiches, burgers, etc. There are always snacks available. Staff overall said they eat the food themselves and it is good. Residents interviewed said there is plenty of food, variety and choices, and the food is good. When asked what happens if someone would like a particular snack or food item that is not stocked in the memory care area, such as a particular kind of cereal, for example, the Culinary Director said the staff can always ask the kitchen for that item and it will be sent over if available; and can be ordered. Staff interviewed were all aware that they can ask the kitchen for particular foods if not available. 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, Dec 3, 2024 · control 59-AS-20241002115441

Allegation investigated: Staff are not assisting residents with hygiene needs

LPA Hiratsuka conducted the investigation into the allegation above. LPA Hiratsuka interviewed staff and reviewed resident records. This allegation was focused on residents who are not receiving showers as per their assigned schedule. Interviews with staff showed some staff have no issues giving showers to residents and some do. The staff have noted the residents who may be difficult to bathe are identified. Executive Director (ED) Patty Uclcray and Resident Care Director Jay James (RCD), both stated they are implementing new training techniques for the staff to have more consistency to be able to talk residents into taking showers instead of refusing. Shower logs show the residents who require assistance with showering sometimes refuse and sometimes accept but the residents do get showered. LPA unable to interview residents in question due to mental capacity Based on the above, LPA cannot prove or disprove because each side has their own version of events. Due to the information gathered, LPA cannot determine the allegations: Staff are not assisting residents with hygiene needs. LPA finds allegation to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 10, 2024 · control 59-AS-20240710112435

Allegation investigated: Staff not checking on residents leaving residents in soiled briefs for many hours

LPA Hiratsuka conducted the investigation into the allegation above, LPA Hiratsuka interviewed staff and reviewed resident records. Interviews stated some residents have been left in soiled briefs for an undermined amount of time and some interviews stated residents have not. Some interviews state residents cannot be put on set schedules of when they need to urinate or defecate because residents do not have control of when they need to do those bodily functions. Residents who have heavier incontinence have been noted in their charts and are supposed to be checked more frequently. Some staff stated the residents are and some stated the residents are not. Some staff stated the residents are supposed to be changed prior to shift change and are not being changed. LPA unable to interview residents in question due to mental capacity. Based on the above, LPA cannot prove or disprove because each side has their own version of events. Due to the information gathered, LPA cannot determine the allegation: Staff not checking on residents leaving residents in soiled briefs for many hours. LPA finds allegation to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 10, 2024 · control 59-AS-20240722102908

Allegation investigated: Staff do not keep the facility free from infestation Staff altered a report involving a resident Staff did not properly report an incident involving a resident

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver compliant findings. LPA met with Patty Uclaray during today’s inspection. LPA investigated the allegation, “Staff do not keep the facility free from infestation”. LPA interviewed residents and staff and obtained facility documentation. Administrator stated there is construction occurring close by and so they have seen an increase in pests at the facility. Administrator stated they have a pest control company that comes to the facility several times a month to take care of any pest issues. LPA interviewed 4 residents in care in which they stated they do not see a pest issue at the facility. Continuation on 9099-C. Unfounded LPA interviewed staff in which they stated if they see any pests, the pest control company will come to the facility and take care of the issue. LPA toured the facility which included resident rooms and common areas and did not observe any pest infestation. Due to the information gathered LPA finds that the allegation is unfounded. LPA investigated the allegation, “Staff altered a report involving a resident”. LPA interviewed residents and staff and reviewed facility reports. LPA interviewed staff in which they stated when an incident occurs the med tech writes a report and then sends the information to management. The management team reviews the information and creates an incident report. Staff interviews indicate that they are not aware of a time when staff have altered a report. Relevant party indicated that a report was altered by management however no specific information was provided. LPA reviewed facility incident reports and found no false information on the documentation that was reviewed. Due to the information gathered, LPA finds allegation to be UNFOUNDED. LPA investigated the allegation, “Staff did not properly report an incident involving a resident.” LPA interviewed staff and reviewed facility information. LPA interviewed staff in which they stated when an incident occurs the med tech writes a report and then sends the information to management. The management team reviews the information and creates an incident report. Administrator stated if needed then management will send incident report into CCL. Administrator stated that all medication errors are reported into CCL. Relevant party indicated that a medication error occurred, and no report was made, however no specific information was given. LPA reviewed incident reports sent into CCL and found facility is sending in incident reports throughout the year on incidents that have occurred with residents in care. Due to the information gathered LPA finds allegation to be UNFOUNDED. The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. Staff stated when a resident falls, the protocol is to call a med tech and the emergency services. Resident is never left alone when they have been found on the floor. Due to the information provided, LPA finds the allegation to be UNSUBSTANTIATED. LPA investigated allegation, “Staff mishandled a resident's medication”. LPA interviewed residents and staff and reviewed resident medication and documentation. LPA interviewed 4 residents in care in which they stated they receive their medications in a timely manner and no medication errors have occurred. LPA reviewed 5 resident medications, comparing medications with physician orders. LPA observed all prescribed and scheduled medications were available to residents. LPA observed of the 5 resident’s medications that were reviewed no medication errors occurred. LPA interviewed staff, and 1 staff member stated medication errors have occurred in the past. Relevant party indicated that a resident was given the wrong medications, but no specific information was provided. Due to the information provided, LPA finds allegation to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview was conducted and copy of report provided.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 59-AS-20240729103359

Type of visit: Required - 1 Year

On 2/15/2024 LPA Tryon visited the facility to conduct an annual visit. LPA met with Director Cathy Dustin and Administrator Trainee Patty Uclaray. The facility currently has 44 residents. LPA toured the facility with Ms. Uclaray including common areas, resident rooms, bathrooms, kitchen, dining area, food storage, hallways, medication rooms, storage for potentially hazardous items and materials. The facility is clean and well-furnished, resident rooms were clean and had appropriate furnishings. Food supplies appeared to be well-stocked to meet the requirement of 2 days perishable and 7 days non-perishable. Food was stored appropriately to maintain freshness. Lunch appeared appealing and appetizing. Medications are centrally stored and locked. Facility keeps centrally stored logs. Controlled substances are double-locked in the medication carts. Chemical storage was viewed, cleaning chemicals are stored in a locked metal cabinet Hot water is within appropriate temperature range. The building has a fire alarm/sprinkler system that is checked regularly. Fire extinguishers present and charged. LPA reviewed the CARE Tool with Administrators. LPA interviewed 3 staff and 2 residents, reviewed 4 resident charts and 5 staff charts. LPA requested copies of current liability insurance proof, administrator certificates. At this time the facility appears to be in substantial compliance with the regulations. No deficiencies cited.the state’s words, verbatim · CDSS document, Feb 15, 2024