Pacifica Senior Living Merced

Allegation investigated: Staff are not able to implement a fire safety plan which poses a risk to residents in care Facility kitchen is not kept clean Staff did not provide good quality foods to residents in care

On 04/29/2026, Licensing Program Analyst (LPA) V Gorban conducted complaint investigation visit, introduced self and was allowed entry. LPA met with administrator Lisa Baricevic. The purpose of this visit is to deliver the findings of the investigation completed by the Department. During the visit, LPA conducted a tour of the facility, interior and exterior to ensure there is no potential or immediate health and safety risk at the facility. Allegations: Staff are not able to implement a fire safety plan which poses a risk to residents in care, Facility kitchen is not kept clean, and Staff did not provide good quality foods to residents in care. Regarding fire safety plan, based on records reviews, facility poses fire and disaster plan, train staff and conduct quarterly disaster drills with staff. Regarding unclean kitchen, based on observation and interviews, kitchen appeared clean and staff clean kitchen after each meal prep. Regarding quality meals, based on records review, records meets regulation expectations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, report signed and copy provided for facility records. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 29, 2026 · control 24-AS-20260311130945

Allegation investigated: Staff did not ensure a plan for residents to be transported downstairs

On 04/29/2026, Licensing Program Analyst (LPA) V Gorban conducted complaint investigation visit, introduced self and was allowed entry. LPA met with administrator Lisa Baricevic. The purpose of this visit is to deliver the findings of the investigation completed by the Department. During the visit, LPA conducted a tour of the facility, interior and exterior to ensure there is no potential or immediate health and safety risk at the facility. Allegation: Staff did not ensure a plan for residents to be transported downstairs. Based on interviews and records review, the facility prepared, and hold in place a disaster plan. Residents were notified via a in house note, contact personnel, and alternative way to transport residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Report continues on attached LIC9099-A Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 29, 2026 · control 24-AS-20260312083540

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 6, 2026

Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not observed as evidenced by: Based on observation, second elevator, (west side of the building) is not operational for prolonged time frame which poses potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: Licensee will follow up and provide updated information regarding elevator repair following plan of correction. With updates, regarding repair to be provided to LPA via email by POC due date.

Type of visit: Required - 1 Year

On 04/29/2026, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct Required Annual Inspection. LPA met with Administrator (AD) Lisa Baricevic. LPA conducted tour inside and out of facility with AD. Residents observed at the facility during meal times. The facility was observed to be at a comfortable temperature of 76 degrees, clean, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 04/14/2026 Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in freezer, refrigerator, and pantry. Food is delivered by US Foods twice a week on Mondays and Thursdays. Refrigerator temperature was maintained at 40.0-degree F. and freezer was maintained at -9-degree F. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested and recorded at 106-degree F. LPA observed securely fastened grab bar and non-skid mat or non slippery surface covered floors in shower area. Medications were stored in a locked medication room in a medication cart and monitored by QuickMar. Medications records reveals no concerns. First Aid Kit was stored in medication room and observed with all required items. LPA toured laundry room and observed chemicals were stored and locked for staff use only. Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents. Exit interview conducted, no deficiencies cited, report signed and provided for facility records.the state’s words, verbatim · CDSS document, Apr 29, 2026

Allegation investigated: Staff does not provide adequate food service to residents Staff does not ensure resident's bathroom is clean Staff did not allow a resident dignity in their relationships with others

On 04/09/2026, Licensing Program Analyst (LPA) V Gorban conducted complaint investigation visit, introduced self and was allowed entry. LPA met with administrator Lisa Baricevic. The purpose of this visit is to deliver the findings of the investigation completed by the Department. During the visit, LPA conducted a tour of the facility, interior and exterior to ensure there is no potential or immediate health and safety risk at the facility. Allegation: Staff does not provide adequate food service to residents. Based on records review and interviews facility provide a variety of food for each meal and in addition alternative menu is available upon request. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff does not ensure resident's bathroom is clean. Based on observation and interviews, resident room appear clean and in repair. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Unsubstantiated Allegation: Staff did not allow a resident dignity in their relationships with others. Based on records reviews and interviews, facility conducting daily activities available to all residents to participate. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, report signed and copy of this report provided to administrator for facility records.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 24-AS-20260330100507

Allegation investigated: Staff did not provide activities for resident Staff did not seek medical attention for resident’s change in condition Staff did not notify authorized representative of resident's change in condition Staff did not ensure medications were dispensed as prescribed

On 12/26/2025, Licensing Program Analyst (LPA) V Gorban conducted subsequent complaint inspection. LPA met with Wellness Director (WD). The purpose of this visit is to deliver the findings of the investigation completed by the Department. During the visit, LPA conducted a tour of the facility, interior and exterior to ensure there is no potential or immediate health and safety risk at the facility. LIC 9099D Allegation: Staff did not provide activities for resident. Based on interviews and records staff follow daily activities according to facility planner posted on the facility wall. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Report continues on attached LIC9099-C Unsubstantiated Allegation: Staff did not seek medical attention for resident’s change in condition. Based on records reviews, R1 was sent out on multiple occasions including May 8th, May 17th, May 19th, and May 30th due to aggression and medication adjustments. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff did not notify authorized representative of resident's change in condition. Based on records reviews, on May 19th family responsible party was notified of the incident via phone call, on May 21st, and May 30th family member either visited R1 or was notified by the facility of R1 behavior. In addition, responsible party signed updated changes of condition increased level of care from level one to level 2 on 5/21/25. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff did not ensure medications were dispensed as prescribed. Based on records review and interviews, medication A and B were administered as prescribed. R1 medication records indicated on May 7th, 20th, 21st, 26th, and 27th, R1 either refused medications or R1 was out of the community with family, per records medications were dispensed as prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Report continues on attached LIC9099-Athe state’s words, verbatim · CDSS document, Dec 10, 2025 · control 24-AS-20250912133337

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Dec 15, 2025

87411 Personnel Requirements. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary...... This requirement was not observed as evidenced by: Based on records review facility failed following Title 22 regulation regarding supervision resulting in one out of eighty four residents acquired facial injury and staff was not aware of the incident. This is poses potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 10, 2025

Plan of correction: The facility administrator or staff will provide a written statement describing on following regulation by POC due date to LPA by email.

Allegation investigated: Staff do not provide adequate supervision resulting in resident falling on multiple occasions.

On 11/20/2025, Licensing Program Analyst (LPA) V Gorban conducted subsequent complaint inspection. LPA met with administrator. The purpose of this visit is to deliver the findings of the investigation completed by the Department. During the visit, LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility. Allegation: Staff do not provide adequate supervision resulting in resident falling on multiple occasions. Based on records reviews resident fall recorded on multiple occasions with no re -appraisal follow up. The department conducted interviews and reviewed records. LPA discussed with Administrator the significance of completing pre-appraisal and needs and services plan for residents in timely manner. Re-appraisal and new needs and services is to be completed upon resident’s change of condition. Deficiency will be cited according to Title 22 regulation on attached LIC9099-D Exit interview conducted, report signed and copy of this report with appeal rights provided to administrator. Substantiatedthe state’s words, verbatim · CDSS document, Nov 20, 2025 · control 24-AS-20250821102719

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Nov 24, 2025

87463 Reappraisals. (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first.. This requirement was not observed as evidenced by: The facility failed to record reappraisal after multiple fall of one out of 83 residents, which poses potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 20, 2025

Plan of correction: The facility administrator will update resident re assessment and will provide updated re assessment to Licensing office to LPA by email by POC due date. Licensee will communicate reassessment with resident responsible party.

Allegation investigated: Unqualified staff providing care to residents Staff are inappropriately increasing resident's rent due for a change in level of care Staff are not responding to resident's call button in a timely manner Staff are accepting residents not in plan of operation

On 08/15/2025, Licensing Program Analyst (LPA) V. Gorban arrived unannounced to deliver findings on a complaint investigation. LPA explained the purpose of the visit to receptionist Tanya Linan and was allowed entry. Administrator Lisa Baricevic was notified and attended the licensing visit. During the course of the investigation, LPA conducted a facility tour, conducted interviews, and reviewed records. The Department has investigated the allegation: Unqualified staff providing care to residents. Based on interviews conducted and records reviewed, personnel records meet the requirements necessary to provide services to residents in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report continues on attached LIC9099-C Unsubstantiated The Department has investigated the allegation: Staff are accepting residents not in plan of operation. Based on interviews conducted and review records, there are two different types of residents accepted by the facility: assisted living and memory care. The facility’s plan of operation addressed the care and restricted health care for the residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. The Department has investigated the allegation: Staff are not responding to resident's call button in a timely manner. Based on records reviews and staff interviews, records revealed that residents (R1, R2 and R3) calls waiting due to not resetting the system after providing care to residents in timely manner. Per residents interviews no concerns regarding call response was stated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. The Department has investigated the allegation Staff are inappropriately increasing resident's rent due for a change in level of care. Based on records reviews and interviews conducted, the facility charged resident (R1) in the amount of $950 instead of $900 per admission agreement contract. The resident was credited back the overcharge amount by the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. Report signed on-site. A copy of this report was discussed and provided to the administrator.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 24-AS-20250514162917

Allegation investigated: Facility staff do not ensure resident is accorded the ability to receive personal phone calls

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility to open this complaint. LPA met with facility Licensee Lisa Baricevic, and explained the purpose of today's visit. Regarding the allegation facility staff do not ensure resident is accorded the ability to receive personal phone calls. The facility does have a landline phone, and a cell phone that residents can use to contact family. Staff will assist the residents with use of the phone upon request. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Nothe state’s words, verbatim · CDSS document, Jun 27, 2025 · control 24-AS-20250619100241

Allegation investigated: Staff do not follow infection control requirements

On 04/17/2025, Licensing Program Analyst (LPA) V. Gorban conducted an unannounced complaint investigation visit on the above allegations. LPA explained the purpose of visit to Administrator Lisa Baricevic. During the course of the investigation, LPA conducted a facility tour, reviewed records, and conducted interviews. The Department has investigated the allegation: staff do not follow infection control requirements. Based on interviews and records reviewed, it was found that the facility is following infection control requirements. LPA discovered that R1 is able to empty and drain their own ostomy bag. Additionally, R2 is receiving care from a hospice agency. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. Report signed on-site and a copy of this report was provided to the Administrator for facility records. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 17, 2025 · control 24-AS-20250411131032

Type of visit: Case Management - Other

On 04/17/2025 Licensing Program Analyst (LPA) V. Gorban conducted unannounced visit regarding health and safety check on residents in care. During this visit LPA Gorban met with facility administrator Lisa Baricevic. The reason for this visit is to follow up on previous complaint investigation and residents interviews that staff do not respond to residents calls in timely manner. Based on residents interviews and records reviews residents calls were not answered for over 20 minutes and other for over an hour. Based on records review and interviews the deficiency will be issued on attached LIC809-D Based on residents file review, R1's physician report has not been updated since 2018. The deficiency will be issued on attached LIC809-D. Exit interview conducted, report signed and copy of this report provide to administrator for facility records.the state’s words, verbatim · CDSS document, Apr 17, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 27, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.. This requirement was not observed as evidenced by: Based on facility records review on multiple occasions facility did not respond to residents calls in timely manner resulting in at least 3 out of 75 residents wait time for assistance in January of 2025 varying from 30 minutes to over an hourthe state’s words, verbatim · CDSS document, Apr 17, 2025

Plan of correction: The facility administrator will monitor call system performance and when system fail to operate, staff will be sent to check on residents health and safety every 15 minutes. Administrator will provide a written plan to LPA by email by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Apr 27, 2025

87506 Resident Records. (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not observed as evidenced by: Based on records reviews, one out of 75 residents have not had updated physician report since 2018. This is poses potential health and safety for clients in care.the state’s words, verbatim · CDSS document, Apr 17, 2025

Plan of correction: The facility administrator will review and update resident physician report and provide a copy of updated report to licensing office or LPA by OC due date.

Type of visit: Required - 1 Year

On 04/17/2025, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct Required Annual Inspection. LPA met with Administrator (AD) Lisa Baricevic. LPA conducted tour inside and out of facility with AD. Residents observed at the facility during lunch time. The facility was observed to be at a comfortable temperature of 76 degrees, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 05/06/2024 Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in freezer, refrigerator, and pantry. Food is delivered by US Foods twice a week on Mondays and Thursdays. Refrigerator temperature was maintained at 39.0-degree F. and freezer was maintained at -10-degree F. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested and recorded at 105-degree F. LPA observed securely fastened grab bar and non-skid mat in shower area. Medications were stored in a locked medication room in a medication cart and monitored by QuickMar. Medications records were reviewed. First Aid Kit was stored in medication room and observed with all required items. LPA toured laundry room and observed chemicals were stored and locked for staff use only. Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents. Report continues on attached LIC809-C Residents’ files were reviewed to have updated emergency contact, Admission agreement, Needs and Services Plan and Pre-Appraisal Plan. A sample of staff files were reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility. Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below: Residential Care Facility for the Elderly (RCFE): · LIC 308 Designation of Facility Responsibility · LIC 309 Administrative Organization · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly Please submit the above forms/information to Fresno CCL by: 04/27/2025 As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed. The observed deficiency was cited during case management visit. An exit interview was conducted with the AD. A copy of this report was given to the AD with appeal rights, whose signature on this form confirm receipt of these reports.the state’s words, verbatim · CDSS document, Apr 17, 2025

Type of visit: Case Management - Other

On 03/20/2025, Licensing Program Analyst (LPA) V Gorban conducted an unannounced Case Management visit. LPA introduced self and allowed entry in to the facility. LPA requested to speak and was accompanied during this visit by facility administrator LPA Gorban toured facility and observed residents having breakfast in the dining room and other residents resting in their rooms. Currently, facility has 20 residents receiving hospice services. During this visit LPA amended deficiency report provided on 3/12/25, requested administrator certificate and provided an updated facility hospice waiver. LPA requested facility files to be provide by 03/21/2025, 5 PM pacific time. Exit interview conducted, report signed and copy of this report provided for facility records.the state’s words, verbatim · CDSS document, Mar 20, 2025

Allegation investigated: Facility staff did not provide resident reappraisal upon change in condition

On 03/12/2025, Licensing Program Analyst (LPA) V Gorban unannounced visited facility stated above to commence a complaint investigation, stated the purpose of the visit and was allowed entry into the facility by Administrator (AD) Lisa . Allegation: Facility staff did not provide resident reappraisal upon change in condition. During this visit LPA toured the facility performing safety checks, also LPA interviewed Administrator, facility staff and resident. Based on interviews and observation R1 did not receive updated documents of re -appraisal due change the level of care, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, are being cited on the attached LIC 9099D Exit interview conducted and copy of this report provided to Administrator for facility records. Substantiatedthe state’s words, verbatim · CDSS document, Mar 12, 2025 · control 24-AS-20250310162656

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(e) · Plan of correction due date: Mar 14, 2025

87507 Admission Agreements. (e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative... This requirement was not observed as evidenced by: facility staff failed to provide the resident with updated re-appraisal for resident knowledge and records. This is poses potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 12, 2025

Plan of correction: The facility administrator will provide education and traning to personnel and provide an official statement were facility will provide a responsible party with any updates made to residents' records to LPA by email following POC due date.

Allegation investigated: Staff do not ensure insect issue is being properly addressed for residents in care

On 11/26/24 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to deliver the finding for the allegation(s) listed above. LPA introduced herself, explained the reason for the visit, and met with Wellness Director- Tracy Gaddess. Administrator (AD) Emily Venegas was not available at the time. 1. The Department investigated the allegation: Staff do not ensure insect issue is being properly addressed for residents in care. LPA conducted interviews and reviewed pictures which were provided. LPA observed a cockroach infestation is resident's room. Based on LPA's observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D. Exit interview was conducted and a copy of this report LIC9099, LIC9099D, and appeal rights were provided to Wellness Director- Tracy Gaddess. Substantiatedthe state’s words, verbatim · CDSS document, Nov 26, 2024 · control 24-AS-20240610092201

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Nov 27, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation & interview, licensee did not comply with the regulations listed above. LPA observed in pictures there was an infestation of cockroaches in the residents room. This poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 26, 2024

Plan of correction: Licensee will have the rooms with insect issues serviced and verificaiton will be sent to LPA.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) M Vega arrived unannounced to conduct a Case Management visit on 10/17/2024 at 10:40 AM. LPA met with facility Front Desk staff, LPA introduced self and presented badge. Front Desk staff obtained contact with Executive Director Emily Venegas. Stated the purpose of visit to Executive Director. LPA served Decision and Order excluding Staff 1 (S1) from being present inside the facility. LPA requested a current and updated Personnel Report (LIC 500) and Guardian account be updated to remove S1 from the facility staff roster. A notice of completion shall be submitted to Community Care Licensing (CCL). LPA informed Executive Director Emily Venegas that S1 is not allowed to be employed and/or on any facility premises. The Decision and Order of Exclusion From All Facilities came into effect as of 05/31/2024 upon receipt of the letter. A copy of the letter was given to facility Executive Director Emily Venegas during this visit. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed and cited. Exit interview held with Executive Director Emily Venegas, A Copy of report given.the state’s words, verbatim · CDSS document, Oct 17, 2024

Type of visit: Required - 1 Year

On 4/23/2024, Licensing Program Analyst(LPA) D. Ayers arrived unannounced to conduct a Required Annual Inspection. LPA met with Executive Director Emily Venegas and announced the purpose of the visit. LPA toured the facility inside and outside. All passageways and exits were clear and free from obstruction. Fire extinguishers were recently serviced and facility had a sprinkler system. LPA reviewed facility emergency disaster plan and record of emergency drills. LPA toured the facility kitchen and observed an adequate supply of perishable and non-perishable foodstuffs. Kitchen and all common areas were clean, well-lit, and odor-free. Facility had adequate supply of emergency food and first aid supplies. LPA toured a sample of resident bedrooms and bathrooms. Bedrooms and bathrooms were clean and odor-free. Bedrooms had required minimum furnishings and were at a comfortable temperature. Bathrooms had secure grab bars and non-slip floors. LPA toured facility memory care unit and observed some residents participating in planned activities. LPA reviewed a sample of resident and staff files. Files contained required documentation and records. LPA requested the following files to be provided by 4/30/2024: LIC 500, LIC 308, LIC 9020a. At 10:15 am, LPA observed that a centrally stored medication was expired, but was still stored in the medication cart with the resident's other medications. During tour of the facility, it was observed that at least three storage bins in resident bathrooms and one in a common bathroom were not fitted with tight-fitting covers. See attached LIC 809D for two type-B deficiencies cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8. A copy of the report and appeal rights were provided to the administrator via email. Exit interview conducted.the state’s words, verbatim · CDSS document, Apr 23, 2024

Allegation investigated: Due to lack of staff, calls for assisance are not answered timely Due to staff neglect, resident missed medications Staff are not following residents care plan Due to neglect, resident has fallen multiple times Authorized representative has not received a copy of the care plan

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings a complaint on the allegations listed above. LPA met with facility Administrator Emily Venegas and explained the purpose of today's visit. Regarding the allegation Due to lack of staff, calls for assistance are not answered timely. LPA Hurt reviewed records titled “Resident Event Report” documenting response times when Resident 1 pushed his pendant alarm. On 01/09/2024 the response time for staff to assist Resident 1 was 80 minutes, on 01/10/2024 the response time for staff to assist Resident 1 was 61 minutes, on 01/11/1024 the staff response time to assist Resident 1 was 55 minutes. Resident 1 stated when pushing his pendant alarm requesting staff assistance, he was having to wait at times more than hour before facility staff assisted. Based on LPAs interviews, and records reviewed which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED Continued.. Substantiated Continued.. Regarding the allegation Due to staff neglect, resident missed medications. LPA Hurt reviewed Centrally Stored Medication Logs, and Medication Administration Record for facility Resident 1. The Centrally Stored log lists several medications to be given daily to Resident 1. The MAR documents Resident 1 was not given most medications from 01/08/2024 to 01/18/2024. Based on records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED Regarding the allegation Staff are not following residents care plan. LPA Hurt reviewed facility records titled “Needs and Services Plan” for facility Resident 1. The Needs and Services Plan documents Resident 1 needs transfer assistance. Resident 1 was waiting over an hour after pushing his pendant for staff to assist with transfer. Based on records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED Regarding the allegation Due to neglect, resident has fallen multiple times. Resident 1 was not assisted timely by facility staff when attempting to transfer resulting in multiple falls. Facility staff did state they attempt to assist all residents when they call for assistance, but they are short staffed and residents are unfortunately having long wait times while they assist other residents. Based on interviews conducted, and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED Regarding the allegation Authorized representative has not received a copy of the care plan. LPA Hurt reviewed records titled “Resident assessment” for facility Resident 1. This document was not signed by Resident 1 or their Responsible party. LPA Hurt interviewed Resident 1’s Responsible Party who stated they requested and were never provided a copy of the “Resident Assessment.” Based on LPA interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED Exit interview conducted with Administrator Emily Venegas, and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 24-AS-20240116092943

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Mar 21, 2024

87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. The following requirement has ot been met as evidenced by: Resident 1's wait time for assistance when pushing his pendant was at times more than 60 minutes, which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: Administrator will ensure sufficient staff is provided to care for facility residents, and provide proof to LPA by POC date of 03/21/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a) · Plan of correction due date: Mar 21, 2024

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. The following requirement has not been met as evidenced by: Resident 1 was not provided medications listed on medication list, which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: Administrator will train facility medication technicians on facility resident admission process and submit proof to LPA by POC date of 03/21/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Apr 3, 2024

87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. The following requirement has not been met evidenced by: Resident 1 was not correctly assisted with medications or transfers as listed on pre admission, which poses a potential, health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: Administrator will conduct training with all facility staff on providing Basic Services for facility residents and provide proof to LPA by POC date of 04/03/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 3, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. The following requirement has not been met as evidenced by: Resident 1 was not assisted by staff with transfers resulting in several falls, which poses a potential , health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: Administrator will conduct staff training on assisting residents timely and submit proof to LPA by POC date of 04/03/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(a)(3) · Plan of correction due date: Apr 3, 2024

87457 Pre-Admission Appraisal - General (a) Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions(3) The prospective resident, or his/her responsible person, if any, shall be involved in the development of the appraisal. The following requirement has not been met as evidenced by: Resident 1's Responsible Party was not provided and did not sign Resident Assesment or Needs and Services plan, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: Adminsitrator will provide training to facility staff on Admission process, and send proof to LPA Hurt by POC date of 04/03/2024.

Type of visit: Case Management - Health Checks

On 12/28/2023, Licensing Program Analyst(LPA) D. Ayers arrived unannounced to conduct a case management inspection. LPA met with Executive Director Emily Venegas and announced the purpose of the inspection. LPA conducted a tour of the facility to ensure that there were no immediate health or safety concerns. LPA requested additional information regarding an incident which occurred 12/19/2023. No deficiencies were cited during the inspection. Exit interview conducted, and a copy of the report was provided to the licensee.the state’s words, verbatim · CDSS document, Dec 28, 2023