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Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator/licensee Kathleen Albano was also present. Administrator certificate #7017523740 06/07/2028 Facility roster and contact information was reviewed. LPA and licensee toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and dates present. Cleaning supplies and sharp knives located in locked closet. Ring camera video surveillance in common areas of facility still present but licensee showed LPA that audio has been disabled and is not active. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 130.1 degrees F in the kitchen but slightly lower in sinks accessible to residents. Water temperature in main bath measured at 123.1 degrees F and 122.5 degrees F in room #6. Licensee immediately adjusted water heater. Licensee advised that facility has been working with plumber to maintain temperatures within regulation of 105 degrees F to 120 degrees F. Facility will continue to work with plumber and adjust water heater temperature according Fire extinguishers were last inspected 9/16/25. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drills were conducted August 2026. Facility has a backup generator for use during a power outage. Continued on 809C... Continued from 809... LPA conducted review of five [5] staff records and six (6) resident records. All required documentation present. 1/2 rail orders all on file. LPA discussed with licensee shadow training for medication per Health and Safety Code 1569.69. LPA and licensee conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. LPA and licensee discussed the maintenance and requirements of a PRN MAR and that it must include the date and time given, the dosage, and the outcome or resident response. LPA discussed with licensee important components of maintaining the Centrally Stored Medication log (CSML). She must maintain current physician's orders and those orders must match what is written on the CSML and the information on the prescription bottle must also match what is recorded on the CSML. LPA and licensee did spot check of Levothyroxine for R1. Per prescription and CSML, quantity of pills was 100. Date started was 6/7/26. R1 takes one pill daily in the morning. So, total remaining in bottle should have been 12 pills. However, LPA and licensee got count of 11 pills (deficiency cited, see 809D). Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, Sep 2, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 3, 2026

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on LPA and licensee observation and record review, the licensee did not comply with the section cited above in that count of Levothyroxine for R1 did not match Centrally Stored Medication Log, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: Licensee will conduct in-service medication training with staff. Plan to train due to CCL by POC date. Training log due 9/10/26.

Allegation investigated: Prohibited health condition is not being handled by a licensed skilled professional Facility Administrator is not present at the facility a sufficient amount of time.

Licensing Program Analyst (LPA) Christi Coppo conducted an unannounced visit and met with Administrator Kathleen Albano. LPA came to the facility to open an investigation into complaint allegations listed above. Complaint alleges that prohibited health condition is not being handled by a licensed skilled professional. Complaintant states that both family and Administrator are not always present to do the feedings, so sometimes resident is not fed or staff is feeding R1 via PEG. Resident R1 required feeding via a PEG tube, which is a prohibited condition. R1 was with Anchor hospice, was discharged from Anchor, and now is back on hospice with Sutter. During investigation, LPA reviewed Anchor hospice care plan. Care plan does not specify the parties responsible for the feedings. LPA asked Admin how she knew on what day and what time the family was available to adminisiter the feedings. Admin answered that they communcated everthing verbally. Continued on 9099C... Unsubstantiated Continued from 9099... Admin reported that there were times that R1 missed feedings. LPA asked Admin if she had a calendar which indicated on what days and times the family would be responsible for the feedings. Admin could not produce any calendar for LPA. Admin was not able to provide any documentation to show who was feeding the resident. Staff and Admin both denied that staff ever fed R1 food via the PEG and interviews with witnesses reported to LPA that staff never fed R1. However, LPA did receive accounting that staff did feed R1 via PEG approximately 3-4 times, but LPA unable to corroborate accounting. Complaint alleges that facility Administrator is not present at the facility a sufficient amount of time. During investigation LPA conducted interviews. It was reported to LPA that Admin has been present at facility between 75%-90% of the time when witnesses were present at the facility or when witnesses called. All witnesses report that Admin is available at all times of the day and week, via text and telephone. Admin advised LPA that she is present at the facility Monday through Friday from 7am to at least 3pm. So, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Sep 9, 2025 · control 21-AS-20250902101530

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Christi Coppo conducted an unannounced visit and met with Administrator Kathleen Albano. LPA came to the facility to open an investigation into complaint #21-AS-20250902101530. While at facility LPA observed pre-poured medications in cups after breakfast had already been served and finished. Admin claims that the pre-poured medications were "left-over" from breakfast. LPA explained that if medications were live-poured, then there would be no "left-over" medications as residents would take them when live poured. Additionally, explained that pre-pouring medication is not in compliance with regulation (deficiency cited, see 809D). Additionally, R1 is with new hospice since 9/6/25, but Admin could not produce copy of hospice care plan. LPA explained that a hospice care plan must be on file for all residents on hospice (deficiency cited, see 809D). Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Sep 9, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Sep 10, 2025

87465 Incidental Medical and Dental Care (h)The following requirements shall apply to medications which are centrally stored: (5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, pre-poured medication present on kitchen island counter, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 9, 2025

Plan of correction: Facility to submit LIC9098 self certifying they will immediately cease pre-pouring medications.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87633(b) · Plan of correction due date: Sep 23, 2025

87633 Hospice Care of Terminally Ill Residents (b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement not met by licensee as evidenced by: Based on LPA and Admin obsevation, hospice care plan not on file for R1, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 9, 2025

Plan of correction: Facility to submit hospice care plan with feeding schedule for R1 to CCL by plan of correction due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator/licensee Kathleen Albano arrived later. Administrator certificate #7017523740 expires 6/7/26. Facility roster and contact information was reviewed. At approximately 10:00am LPA and licensee toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Cleaning supplies and sharp knives located in locked closet. During tour of facility, licensee and LPA observed butcher knife left unattended on kitchen island with residents present less than 2 feet away at dining table (deficiency cited, see 809D). During tour LPA observed ring camera video surveillance in common areas of facility as well as outside in backyard and at front door. Licensee confirmed that cameras have audio. LPA advised cameras cannot have audio as that is a personal rights violation. LPA advised that video surveillance can be present in common areas as long as the surveillance has been disclosed to residents and/or their responsible party, however the surveillance cannot include audio (deficiency cited, see 809D) All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 94.5 in bathroom between rooms #4 and #5 and 102.9 degrees F in bedroom #3 which is not within the allowable range of Continued on 809C... Continued from 809... 105 to 120 degrees F. But water temperatures measured at 106.6 degrees F in bathroom by room #2, and 111.7 degrees F in the kitchen which is within the allowable range of 105 to 120 degrees F. Licensee advised due to facility having 2 water heaters water has to be turned on in the laundry room in order to get hot in those rooms measuring out of regulation. LPA advised water must be hot within a reasonable amount of time, at least within 2-3 minutes of hot water being turned on. LPA discussed with licensee that a resident is not going to know or even have access to the laundry room in order to turn the water on so that they can get hot water to come out of faucet (deficiency cited, see 809D). Per licensee, facility has a plan to complete an expansion, but construction has not started as they have not received building permit. Licensee and drafter of blueprints went to the city of Santa Rosa's Building Permit building and showed the preliminary sketches, but that is as far as they have gotten in the process. LPA advised that LPA has concerns of potential disruption to residents in care, due to noise that this project could cause. LPA requested written plan to be submitted to CCL prior to start of the expected construction along with copy of building permit from the City of Santa Rosa. The written plan should address how the facility will ensure the health and safety of residents in care while the construction occurs, as well as materials and equipment handling to ensure they are inaccessible to residents in care. Staff will be required to continuously remind and check all residents to make sure that they are not going to the construction site and notify their responsible parties. Facility would like capacity increase from 6 to 9 residents after expansion complete. LPA advised once fire clearance is granted LPA will return to facility to complete inspection for capacity change. Fire extinguishers were last inspected 9/30/24. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drills were conducted 8/15/25. Facility has a backup generator for use during a power outage. At approximately 12:00pm LPA conducted review of five [5] staff records. All required documentation present. However, LPA and licensee discussed training materials. LPA and Admin discussed number of hours reported in one day for training. Licensee clarified that she does not complete the training all in one Continued on 809C(2)... Continued form 809C... day, but spreads it out over the entire year. LPA and licensee discussed using updated materials, published within the decade, so as to provide the most current information regarding dementia care. LPA will send licensee link of approved training vendors and licensee will determine if she will continue conducting her own training or instead use an approved vendor. At approximately 1:00pm LPA conducted a review of five [5] resident records. All required documentation present. 1/2 rail orders all on file.. At approximately 2:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. LPA and licensee discussed the maintenance and requirements of a PRN MAR and that it must include the date and time given, the dosage, and the outcome or resident response. LPA discussed with licensee important components of maintaining the Centrally Stored Medication log (CSML). She must maintain current physician's orders and those orders must match what is written on the CSML and the information on the prescription bottle must also match what is recorded on the CSML. LPA and licensee did spot check of Quetiapine for R1. Per prescription and CSML, quantity of pills was 90. Date started was 7/20/25. R1 takes one pill daily at bedtime. So, total remaining in bottle should have been 59 pills. However, LPA and licensee got count of 37 pills (deficiency cited, see 809D). Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Aug 20, 2025

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: Staff mismanaged medication Personal rights

Licensing Program Analyst (LPA) Christi Coppo conducted an unannounced visit and met with Administrator Kathleen Albano, Administrator. LPA came to the facility to open an investigation into complaint allegations listed above. Admin had to leave after interview with LPA. Admin gave caregiver permission to sign report. During today's visit, LPA conducted interviews and made observations. Complaint alleges personal rights. Complainant states they observed medication pill on the floor of facility, notified caregiver, and caregiver picked it up and put it in the kitchen drawer that stores the pre-poured medication. During investigation, LPA observed kitchen drawer that stores medication boxes to be empty, no pre-poured medications present. LPA interviewed Admin about medication allegation. Admin reported to LPA they know that pills on the floor have been a problem as some of the residetns put the pills in their pocket rather than taking them. Continued on 9099C... Substantiated continued from 9099... Admin explained that sometimes there are residents that just put their meds in their pocket rather than taking them. We sometimes see meds on the floor because the residents didn't put it properly in their mouth, but we dispose of it properly. Admin explained to LPA that they know the proper procedure for disposal, either take to pharmacy to destroy or put in water solution to dissolve and destroy, but some of the staff might have overlooked a pill on the floor. Admin indicated she has trained staff on how to properly dispose of contaminated medication pills. LPA and Admin discussed that going forward, caregivers and/or Med Techs staying with residents and witnessing them put the pills in their mouth and swallowing them. Based on LPA’s interview with Administrator, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Complaint alleges personal rights. Complainant states that there is a sliding lock present on the bottom of the front door preventing residents and visitors from entering or exiting without assistance from a staff member. LPA asked Admin about the lock present at the bottom of the front door. Admin advised that they are having trouble with a resident R1, several times R1 tried to elope. Admin explained that the addition of the lock is recent. R1 has had several sundowning episodes where they open the front door and want to get out. We try to redirect by giving activities, but redirecting does not always work. LPA advised that facility must be staffed such that there is adequate staff to both redirect and attend to the other residents. Admin understands and acknowledges re-directing is key. Caregiver immediately removed lock from bottom of door in LPA's presence. Based on LPA’s observation and interview with Administrator, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with caregiver. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with caregiver and a copy of this report was given.the state’s words, verbatim · CDSS document, Oct 16, 2024 · control 21-AS-20241008152519

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(f)(2) · Plan of correction due date: Oct 30, 2024

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia (2) Over-the-counter medication, nutritional supplements or vitamins... This requrement was not met by licensee as evidenced by: Based on LPA interview with Admin medication pills have been found on the floor of the facility, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 16, 2024

Plan of correction: Facility to train staff on medication management. Facility to submit staff training log for all facility staff by plan of correction due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(l)(6) · Plan of correction due date: Oct 17, 2024

87705 Care of Persons with Dementia (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (6 Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. This requriement was not met by licensee as evidenced by: Based on LPA interview and observation facility had sliding lock present on bottom of front door to address sundowning behavior and attempted elopment of resident..the state’s words, verbatim · CDSS document, Oct 16, 2024

Plan of correction: Facility removed lock in LPA's presence. Deficiency cleared.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Kathleen Albano arrived later. Facility contact information was reviewed. At approximately 9:30am LPA and caregiver toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food in refrigerator had open items covered but not labeled with date of opening/storing. Food observations include: refrigerator drawer of radishes were covered in black substance and spots. Refrigerator drawer liner covered with black spots of a black substance and contained wilted and browning celery with brown liquid, and lemon and orange with white and blue fuzzy substance (deficiency cited, see 809D). LPA discussed with Admin their practice of freezing milk. LPA observed frozen milk to be stamped with a best if used by date that has expired by one day. LPA advised to keep fresh milk on hand or if they must freeze the milk to please defrost and use by best if used by date. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 106.8.and 111.3 degrees F which is within the allowable range of 105 to 120 degrees F. One [1] of two [2] main bathrooms had cabinet containing toxins not was locked but had locking function (deficiency cited, see 809D). LPA inspection of garage revealed a walled off storage room used as a sleeping area for staff and included fan, bed, and stereo. LPA advised Admin they can either submit a LIC200 with an updated facility sketch to CCL to request fire clearance for the room, or remove all items from that room and cease have any staff use it. Continued on 809C... Continued from 809... as a sleeping quarter. Admin chose to remove all items from storage room in garage and cease using it as a sleeping quarter. Admin to submit pictures of storage room with all personal sleeping items removed to CCL by 8/9/2024. Fire extinguishers were last inspected 9/21/2023. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drills were conducted 4/11/2024. LPA advised that emergency drills must be performed every quarter. Facility has a backup generator for use during a power outage. At approximately 11:00am LPA conducted a review of five [5] out of [5] resident records. R1 has diagnosis of dementia, but most recent physician's report dated 5/15/2023 did not have all pages present, last page with doctor signature line not present, the next most current physician's report dated 2020. R1's most recent appraisal dated 5/5/2023 (deficiency cited, see 809D). Half rails present on five [5] out of [5] resident beds, however none had doctor's order on file. At approximately 12:30pm LPA conducted review of 5 staff records. S1 did not have fingerprint clearance. Per Admin, S1 was present at the facility on 7/25/2024 and was in training. Per Guardian, the fingerprint clearance status of S1 is "in process," but not yet showing a clearance determination of eligible (deficiency cited, see 809D). LPA advised Admin that S1 may not be present at or working in the facility, whether training or working, until fingerprint clearance is obtained and Guardian shows S1 with a clearance determination of eligible. S2 did not have current training completed (deficiency cited, see 809D). S3 did not have a Health Screen on file, however TB clearance via chest xray was on file. At approximately 2:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies cited. Administrator Kathleen Albano Administrator Certificate 7017523740 expires 6/7/2026. All fees are current as of this time. Continued on 809C(2)... Continued form 809C... Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiences within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Aug 2, 2024

The state marks this report as 11 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.