Pacific Gardens

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management visit. LPA Rai met with Administrator, Matt Zahodne and stated the purpose of today's visit. The purpose of the visit was to follow up on an exception request for resident R1 that the facility submitted to the Department on 06/19/2026. ADM submit a formal request letter requesting an Exception for R1’s Stage 3 pressure injury, along with other supporting documents. During visit, LPA Rai spoke with Administrator, Matt Zahodne and Director of Resident Care Services, Vina Estella. LPA Rai obtained copies of the following documents: R1's Progress Notes, R1's Physician's orders related to the pressure injury and R1's Home Health notes related to the pressure injury. LPA Rai suggested for Administrator to review PIN 22-24-ASC "Collaborating with Home Health Agencies and Hospice Agencies to Provide Care to Residents" since facility staff are collaborating with Home Health Agencies to oversee R1's pressure injury. This report was reviewed with Administrator, Matt Zahodne and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 1, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Administrator, Matt Zahodne and stated the purpose of today's visit. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the facility to include at random 5 resident rooms, activity room/common area room in both Assisted Living and Memory Care units, dining room and kitchen. 5 Out of 5 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The hot water temperature in the bathroom sink ranged from 108.3 - 111.9 degrees F. Fire extinguisher was observed and inspected on 04/15/2026. Facility sprinkler system was inspected and passed by third party vendor on 12/04/2025. The last disaster drills were conducted on 08/19/2026 and 05/13/2026. LPA Rai observed a complete first aid kit at the facility. LPA Rai reviewed facility records for 5 staff and 5 residents. LPA Rai reviewed resident medications and central stored medication records. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Matt Zahodne and a copy of the report was provided. LIC 858 and LIC 859 were provided.the state’s words, verbatim · CDSS document, Aug 21, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst Manuel Monter conducted an unannounced case management visit-incident regarding an incident report, which stated a resident had eloped from the facility. LPA met with Administrator Matthew Zahodne LPA explained the purpose of the visit. On June 4, 2026, the Department received an incident report (IR) regarding resident R1. The IR stated, on May 28, 2026, around 6:28pm, care staff reported that they could not find R1 inside. R1 was last seen sitting in the front lobby around 6:15pm. Staff began searching building and around the neighborhood for R1. While a staff member called into the local police for assistance, R1 was spotted at 1114 Reed ave roughly two blocks from community. Local Law Enforcement (LLE) had already located R1 as neighbors called in that an elderly individual was walking in the neighborhood and seemed confused. LLE called community while they were on hold. Staff brought resident back to the community. On June 9, 2026, LPA interviewed staff and resident R1. At this time, this case in under review and department will conduct a follow visit , if warranted. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Matthew Zahodne and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 9, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management - Incident visit in regards to an Incident Report the Department received on 04/03/2026. LPA met with Administrator, Matt Zahodne and stated the purpose of the visit. On 04/03/2026, the Department received an LIC 624 Incident Report stating on 03/28/2026, resident R1 had an unwitnessed fall in R1's room wherein R1 had blood on R1's right arm. R1 was taken to the hospital and resident returned to the facility the same day. During today's visit, LPA Rai conducted interview with Administrator. LPA Rai obtained copies of the following documents to included but not limited to R1's LIC 602A Physician's Report and R1's Appraisal/Needs and Services Plan. At this time, this case in under review and the Department will conduct a follow up visit, if warranted. This report was reviewed with Administrator, Matt Zahodne and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 3, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced case management visit to amend a complaint. LPA announced the purpose of the visit. LPA met with Mathew Zahodne, Administrator. On 02/04/26 LPA delivered a complaint control number 26-AS-20251103095327. LPA amended the report to include additional information. The complaint findings remain unsubstantiated. The report has been amended and reviewed with the administrator. No deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22. A copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 27, 2026

Allegation investigated: Staff caused an injury to a resident while in care Staff did not timely address a resident's change in medical condition while in care

On 02/04/26 Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced complaint investigation visit to deliver findings. LPA announced the purpose of the visit and met with Matthew Zahodne. During visit LPA interviewed 2 staff including ADM and obtained pertinent Resident documents. On 11/03/25 the department received a complaint with the above allegations. On 11/03/25 LPA Yanez conducted an initial complaint investigation visit and obtained pertinent documents. Page 1 of 3 Unsubstantiated page 2 of 3 During the investigation the department interviewed 1 witness, 3 residents and 5 staff. Resident R1 moved into the Memory Care Unit on 08/03/23 due to wandering behavior. R1 behavior log showed aggressive behavior dated 09/09/24, 11/27/24, 07/21/25, 08/25/25, 08/26/25, 09/09/25, 09/23/25 10/24/25, 10/25/25 10/26/25, 10/28/25 and 10/31/25. R1s Appraisal Needs and Services Plan was updated 10/22/25 and states R1s family to be notified and to try to redirect resident. R1s behavior became a danger to him or herself and facility informed R1s family during an incident and R1s family would arrive to assist in calming R1 down. On 10/31/25 the department received a special incident report regarding R1 having behavior and altercation with staff that occurred on 10/26/25, the incident report stated that R1 had behavior and attempted to kick and punch staff and suffered a finger fracture. On 10/31/25 after the incident R1 went to the hospital via ambulance where R1 became aggressive with hospital staff. R1 did not return to facility after incident. Witness (W1) stated that R1s behavior was due to the facility not forcing R1 to take his/her medication. W1 was reminded that facility staff cannot force Resident to take medication, and it is noted in their file when they refuse medication. W1 stated that the facility should use more force in R1 taking his/her medication. R1s responsible party was called every time resident had behavior and would come to the facility to try to calm R1 down. W1 stated that R1 would calm down once he/she saw them. 5 out of 5 staff stated that R1s aggression and behavior had escalated from the time resident moved into the Memory Care unit and had aggressive episodes and would punch caregivers. 5 out of 5 staff stated that on 10/31/25 R1 had behavior and attempted to pull S1s fingers back and while pulling S1s fingers back was flailing his/her arm. R1 was also observed to have kicked and punched 2 other staff that were present. 3 out of 3 staff stated that R1 had accidentally hit him/herself and R1s nose began to bleed. S3 stated he/she called 911 and shortly after paramedics arrived with local law enforcement and took R1 to the hospital. Page 3 of 3 Amended report On 10/31/2025, at approximately 0951 hours, R1 was brought to the Emergency Department (ED) from the facility by ambulance after becoming agitated and physically engaging with S1 while receiving his/her morning medication. R1 was diagnosed with a “minimally displaced nasal bone fracture, medical documentation determined that the fracture could have resulted from an unwitnessed fall, or from an altercation, because R1 noted that he/she was elbowed in the nose by S1. On 10/30/2025, R1 suffered an unwitnessed fall, staff called EMT’s, but since R1 was at baseline, R1s POA preferred R1 not to be transferred to the ED. S2 has had training in handling critical incidents and is called when staff need assistance with resident who are having behavior in de-escalating techniques including redirecting agitated residents. S2 uses techniques like using a preferred activity to diffuse resident behavior. S2 stated that when a resident attempts to physically engage with staff the staff disengage and move residents nearby for safety and attempt to de-escalate the situation. S2 stated that after any incident the family is immediately notified as well as the Residents primary care physician. S2 stated that R1s behavior is triggered when R1 has nothing to do. S2 would give R1 daily tasks like pouring water into cups when handing out medication to residents to engage R1. R2 stated that he/she had seen R1s recent behavior had become more aggressive. R2 stated that R1 on one occasion was seen pulling on S1s fingers and S1 was not able to pull away and R1 was out of control and had uncontrollable rage. R2 stated that he/she felt that staff did not overstep their boundaries with R1. R2 stated that R1 could possibly hurt him/herself due to the flailing arms and trying to hit staff. Based on investigation, interviews conducted, and records reviewed, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. This report was reviewed with Matthew Zahodne, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 4, 2026 · control 26-AS-20251103095327

Type of visit: Required - 1 Year

On 8/26/2025,Licensing Program Analyst (LPA) Grace Donato conducted an unannounced Required 1 Year visit. LPA met with Executive Director, Matthew Zahodne and explained the purpose of the visit. During visit, LPA toured the inside and outside of the facility. Some residents are currently in the dining room for lunch. Some memory care residents are engaged in activities. Hot water was tested and the temperature was 114 deg F. Facility has sprinkler system. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floors.. LPA toured that kitchen and it was observed that there is an adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter. Six resident records and six staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic 20hr requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. LPA received the following document: Liability Insurance. No deficiencies are cited at this time. Report is reviewed and a copy is provided.the state’s words, verbatim · CDSS document, Aug 26, 2025

Allegation investigated: Resident sustained an unexplained injury while in care. Facility staff did not seek timely medical attention for resident.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Director of Resident Care Services, Vina Estella and stated the purpose of today’s visit. On 03/04/2025, the Department received a complaint with the above allegations. On 03/05/2025, the Department conducted an initial investigation at the facility. It was alleged that resident (R1) sustained an unexplained injury while in the care of the facility and facility staff did not seek timely medical attention for R1 related to the injury. Continuation on LIC 9099-C, Page 1 of 3. Unsubstantiated Page 2 of 3. On 3/3/2025, the facility reported on LIC 624 Incident Report regarding facility staff observed resident (R1) bleeding from the left elbow. The facility staff provided necessary first aid by cleaning the area and applied bandage. The facility staff assessed R1 and R1 did not complain of being in pain and had the ability to move the left arm. R1 did not recall how he/she sustained the injury. On 3/17/2025, the Department interviewed Witness (W1). W1 stated the facility staff did inform W1 regarding R1’s “scratch” which occurred on 3/3/2025 and staff were not able to say how the scratch occurred. W1 stated R1 was admitted to the hospital on 3/3/2025 for pneumonia, hip fracture and swollen feet. On 3/28/2025, the Department interviewed six staff (S1-S6). Three out of six staff stated they did not observe bruises or injuries prior or 3/3/2025. Two out of six staff stated there were no issues report regarding R1 during nocturnal shift, the night before 3/3/2025. Two out of six staff stated R1 was found with a bruise the day of 3/3/2025. Three out of six staff stated they did not observe any falls or incidents related to R1. Two out of the six staff stated R1 was a fall-risk resident. Three out of six staff stated they observed bruises on R1 which were self-inflicted during R1’s behavioral expression when R1 was agitated. S2 stated R1 has a habit of swinging arms when R1 is agitated. S5 assessed R1 on 3/3/2025 when R1 was bleeding from elbow and required first aid assistance. S5 assessed R1’s upper extremities and provided first aid care by applying a band aid over the elbow. S5 stated R1 was not in pain which was assessed through R1’s facial expression and verbal confirmation. S5 stated he/she observed R1 did not have pain in his/her legs therefore S5 did not assess R1’s lower extremities. On 6/3/2025, the Department interviewed three residents (R1-R3). Three out of three residents stated they were not aware of R1’s injury or incidents involving R1. Three out of three residents stated the facility staff are available to provide care and assistance if needed. Three out of three residents stated the facility staff check up on them regularly. Page 3 of 3. Based on review of R1’s Progress Notes dated 3/2/2025, R1 was observed by facility staff to be sitting on the floor, staff attempted to assist R1 but R1 was agitated. After staff’s requests, R1 stood up and sat on the sofa. Based on review of R1’s Progress Notes in February 2025, there were no notes regarding incidents involving R1 falling or unusual incidents, but there were notes regarding R1’s repetitive behavior regarding R1’s refusal for staff assistance, spitting and wandering. Based on review of R1’s Appraisal dated 1/20/2025, R1 is non-ambulatory and is not able to walk without physical assistance wherein R1 uses a walker. R1 does not require assistance transferring in and out of bed/turning in bed or chair. Based on review of documented meeting notes between Facility staff, including Administrator (ADM) Matt Zahodne and R1’s responsible party, three meetings took place between 2/18/2025 – 3/3/2025. All three meetings were regarding R1’s aggressive behavior towards staff and residents. Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Director of Resident Care Services, Vina Estella and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 18, 2025 · control 26-AS-20250304144818

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management - Incident visit in regards to an Incident Report the Department received on 02/05/2025. LPA met with Administrator (ADM) Matt Zahodne and stated the purpose of the visit. On 02/05/2025, the Department received an LIC 624 Incident Report stating resident R1 was administered the wrong medication by Staff S1 on 02/02/2025. Per Report, R1 did not have any bad interactions and R1's responsible party and physician were informed. During today's visit, LPA Rai conducted interviews with 2 staff, including ADM. S1 stated he/she administered resident R1 the medication for resident R2. S1 admitted the names of R1 and R2 were similar and didn't realize the mistake until S1 was administering medication to R2 and realized the medication cup was empty. S1 and ADM stated R1 did not have any reaction to the medication and there are no new orders for R1. Based on review of R1's facility records, R1's physician was notified of the incident and provided the vitals log of the resident following the incident. R1's physician noted the incident and did not give further instructions. Per R1's progress notes, R1's family member was informed of the incident. LPA Rai reviewed S1's training logs on medication training which includes Providing Medication Assistance and Avoiding Common Medication Errors. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. ADM stated S1 and other staff who are responsible to administering resident's medications were provided in-service training and additional hands-on training. ADM will provide in-service training records by Monday, 04/07/2025. At this time, LPA Rai determined this case management needs further investigation. This report was reviewed with Administrator (ADM) Matt Zahodne and a copy of the report was provided. .the state’s words, verbatim · CDSS document, Apr 4, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Simi Rai arrived unannounced to conduct an case management visit to follow up on Incident Report/Death Report for resident (R1) who sustained injury from a witnessed fall and passed away a few days later. LPA Rai met with Administrator (ADM) Matt Zahodne and stated the purpose of today's visit. On 1/21/2025, the Department received an Incident Report for an incident which occurred on 1/13/2025 wherein R1 had a witnessed fall in the activity area in the Memory Care unit while participating in ball toss activity. R1 stood up and lost balance and fell to the floor. The facility staff called the paramedics and R1 was taken to the hospital. The Department received a Death Report on 1/24/2025 wherein R1 passed away at family member's home under Hospice services after being discharged from the hospital on 1/17/2025. During today's visit, LPA Rai interviewed one staff (S1) and ADM. LPA Rai obtained copy of R1's Physician's Report dated 11/4/2024 and staff training records such as "Identifying Fall Risk in Assisted Living" for staff working during the shift of 1/13/2025. ADM stated to provide a copy of the Death Certificate when it becomes available. At this time, LPA Rai determined this case management needs further investigation. The report was reviewed with Administrator (ADM) Matt Zahodne and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 27, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Simi Rai and Marcella Tarin conducted an unannounced Required 1 Year visit. LPAs met with Director of Resident Care Services, Mia Evangalista and stated the purpose of today's visit. LPAs spoke with Administrator Matthew Zahodne over the phone and stated the purpose of today's visit. Administrator gave permission for Director of Resident Care Services, Mia Evangalista to review and sign this report. During visit, LPAs toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPAs Rai and Tarin toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPAs observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPAs toured at random 7 resident bedrooms. 7 out of 7 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from between 105 degrees F and 120 degrees F. Fire extinguisher was observed and inspected on 04/09/2024. Facility smoke detectors and carbon monoxide detectors were in working condition. Third party vendor was on premise during today's visit and tested all smoke detectors and carbon monoxide detectors. The last disaster drills were conducted on 4/21/2024 and 7/28/2024. LPAs reviewed facility records for 7 staff and 7 residents. LPA Rai reviewed resident medications and central stored medication records. No deficiencies were cited per California Code of Regulations, Title 22. Technical Violations were provided during visit. LPAs discussed the report with Administrator Matthew Zahodne over the phone. This report was reviewed with Director of Resident Care Services, Mia Evangalista and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 14, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit regarding an Incident Report sent the Department. LPA met with Administrator (ADM) Matthew Zahodne and stated the purpose of the visit. On 1/11/2024, the Department received an Incident Report for resident (R1) for an incident which occurred on 1/6/2024 where R1 climbed out of his/her bedroom window and was found walking outside of the back of the building. During today's visit, LPA Rai conducted 4 interviews with staff, (S1-S3) including ADM. LPA reviewed R1's records to include R1's Appraisal 11/2/2023, Functional Capability 11/2/2023, Appraisal/Needs and Services Plan dated 12/18/2023 & 1/6/2023 and Physician's Report dated 11/1/2023 & 12/13/2023. LPA Rai reviewed R1 is not able to leave the facility unattended and R1 is diagnosed with Dementia. LPA Rai observed R1's current room and observed window stoppers placed in the window. ADM stated the maintenance team will be placing window stoppers on all windows in the Memory Care Department. No deficiencies were cited at this time as per California Code of Regulations Title 22. Technical Assistance and Technical Violation was provided. This report was reviewed with Administrator Matthew Zahodne and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 18, 2024