Pacifica Senior Living Union City

Type of visit: Case Management - Other

On 07/13/2026 at 9:00 AM, Licensing Program Analysts (LPAs) K. Nguyen and P.Manalo conducted an unannounced Case Management visit regarding R1's stage 3 pressure ulcer. LPAs met with Executive Director (ED), Marie Ann Lagasca-Cruz and explained the purpose of the visit. On 07/10/2026, LPA K. Nguyen received an email from the facility regarding R1's stage 3 pressure ulcer and R1's family decline hospice services. During the visit, LPAs reviewed and obtained the following documents included but not limited to Physician Communication Form and Email Correspondence. ED stated that during R1's follow up appointment with physician, physician stated that R1 had a stage 3 pressure ulcer. However, Kaiser nurse and home health nurse stated that R1's pressure ulcer is a stage 2. By 07/17/2026, LPAs are requesting additional documentation's from Kaiser and home health stating what stage the pressure ulcer for R1 is. LPA may return at a later time. No deficiencies cited. Exit interview conducted and copy of this report is provided.the state’s words, verbatim · CDSS document, Jul 13, 2026

Type of visit: Required - 1 Year

On 07/13/2026 at 9:30 AM, Licensing Program Analysts (LPAs) K.Nguyen and P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Marie Lagasca-Cruz, and explained the purpose of the visit. LPAs toured the facility inside and out including but not limited to 6 residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observe that lighting in all rooms is adequate for the comfort and safety of the residents. Hallway temperature was maintained at 73 degrees F. The hot water temperature in a sample of residents’ shared bathroom were measured at 113, 112.6, 112.6 and 108.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid shower pans. Carbon monoxide detector were in operating condition during visit. Fire Alarm System Inspection was last conducted on 04/02/2026. Fire extinguisher was last serviced on 10/04/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 04/22/2026. At 10:48 AM, LPA reviewed 7 staff records and 7 of 7 are associated with the facility and have first aid certification. At 11:12 AM, LPA reviewed 6 residents' records. At 12:45 PM, LPA reviewed a sample of residents’ medications. No deficiencies cited. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 13, 2026

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff failed to provide proper care and supervision to resident having suicidal ideation Staff failed to accord privacy to resident in care

On 4/14/26 at 10 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a 10-day initial complaint and deliver findings of the above allegations. LPA met with Executive Director, Marie Lagasca-Cruz, and explained the purpose of the visit. Allegation: Staff failed to provide proper care and supervision to a resident having suicidal ideation- Unsubstantiated During the investigation, the Licensing Program Analyst (LPA) conducted interviews with the Executive Director (ED), six (6) staff members, and eight (8) residents. LPA reviewed a sample of eight (8) resident files and collected documents, including, but not limited to, the staff roster with contact information, resident roster, resident admission agreements, physician reports, care plans, narrative charting, progress notes, and communication log. Report Continues on LIC 9009c… Unsubstantiated Report Continue LIC 9099… It was alleged that staff failed to provide proper care and supervision to a resident having suicidal ideation. LPA reviewed a sample of eight (8) resident files and gathered various documents, including but not limited to: the staff roster with contact information, resident roster, resident admission agreements, physician reports, care plans, narrative charting, progress notes, and communication log. In addition, the LPA interviewed the Executive Director (ED), seven (7) staff members, and eight (8) residents. All seven staff members stated that if a resident expresses any suicidal ideation, they are trained to ask leading questions, help redirect the resident to understand their thoughts better, and immediately report the situation to the ED or director, who would then contact the Union City Police Department. All eight (8) residents interviewed stated that staff provides appropriate care and supervision whenever residents express—or if they were ever to express—suicidal ideation to staff or anyone else. One resident (R1) clarified, “I do not have any suicidal ideation thoughts. I called the crisis team to talk, but I never mentioned that. I am mad that people keep on asking.” R1 stated, “staff do their round check and check in with me every hour”. Report Continue on LIC 9099c1... Report continue on LIC 9099c1... Allegation: Staff failed to accord privacy to the residents in care- unsubstantiated During the investigation, the Licensing Program Analyst (LPA) conducted interviews with the Executive Director (ED), six (6) staff members, and eight (8) residents. The investigation focused on the allegation that staff failed to respect residents’ privacy or provide adequate privacy for them. The LPA also reviewed relevant facility documents, including staff schedules, resident records, care plans, and policy and procedure manuals regarding resident privacy. During interviews, all eight residents stated that staff consistently provide privacy during personal care activities, such as bathing, dressing, and medical treatment. Several residents mentioned that staff always knock before entering their rooms and ensure doors and curtains are closed when privacy is needed. Residents also reported that staff respect their privacy when they are talking on the phone, ensuring conversations remain private and uninterrupted. No residents interviewed reported concerns about their privacy or described any incidents in which privacy was not respected. R1 stated, “They give me privacy, staff are always there in the med room”. Both staff and residents consistently reported that privacy is maintained during care. Based on the preponderance of evidence, the allegations are unsubstantiated. No deficiencies were cited regarding this allegation. An exit interview is conducted, and a copy of this report is provided.the state’s words, verbatim · CDSS document, Apr 14, 2026 · control 15-AS-20260409145528

Allegation investigated: Staff do not ensure resident is provided with activities.

On 4/9/26 at 9AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct 10-day initial complaint and deliver findings for the above allegations. LPA met with Executive Director, Marie Lagasca-Cruz and explained the purpose of the visit. Allegation: Staff do not ensure resident is provided with activities - Unsubstantiated During the course of the investigation, Licensing Program Analyst (LPA) conducted interviews with the Executive Director (ED), six (6) staff members, and fifteen (15) residents. The ED stated that the facility maintains a monthly activity schedule which includes, but is not limited to, group exercises, games, movie time, and community outings. Staff interviewed indicated that residents are informed of scheduled activities and are encouraged to participate; however, participation is voluntary based on resident preference. Report Continues on LIC 9009c… Unsubstantiated Report Continue… LPA reviewed a sample of six (6) resident files and collected documents including, but not limited to, the staff roster with contact information, resident roster, resident admission agreements, physician reports, care plans, end-of-shift notes, and the facility activity calendar. Additionally, LPA toured the facility including but not limited to the assisted living, memory care unit, activity room and common areas. During the visit, LPA observed that both the assisted living unit and memory care unit were actively engaged in scheduled activities. LPA interviewed six (6) staff and fifteen (15) residents. Staff reported that residents are informed of scheduled activities, encouraged to participate, and offered assistance as needed; however, participation is voluntary and based on individual resident preference. Residents provided mixed responses. Some residents reported that they are aware of and participate in activities offered at the facility and expressed satisfaction with the variety and frequency. Other residents indicated that they choose not to participate or prefer to engage in independent activities such as watching television, reading, or resting in their rooms. No residents reported being prevented from participating in activities or stated that staff refused to provide access to activities. Additionally, LPA interviewed Resident 1 (R1), who was observed smiling, moving R1 head, and appearing to enjoy music during the visit. When asked whether staff check in and inform R1 about activities, R1 responded “yes.” R1 also confirmed that staff offer to engage in activities, inform R1 about scheduled activities, and that R1 enjoys listening to music. In addition, LPA reviewed the facility’s activity schedule and observed posted activity calendars in common areas. Documentation reviewed supports the idea that activities are planned and made available to residents on a regular basis. Although some residents expressed personal preferences not to participate, there is insufficient evidence to support the claim that staff failed to ensure activities were provided. Therefore, the allegation is unsubstantiated at this time.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 15-AS-20260406095723

Allegation investigated: Staff mismanaged resident's medications. Staff are not properly trained to administer medications. Lack of supervision resulting in resident sustaining a fall. Facility is not ensuring a staff is on duty on the premises overnight

On 7/14/2025 at 9:45 am, Licensing Program Analysts (LPAs), K. Nguyen and P. Manalo arrived unannounced to deliver findings for the above allegations. LPAs met with Executive Director, Marie Lagasca- Cruz and explained the reason for the visit. Allegation: Staff mismanaged resident's medications- UNSUBSTANTIATED It was alleged that the Staff mismanaged residents’ medications. However, during the investigation, LPAs reviewed R1 Physician report, Admission orders, Identification and Emergency Information, R1 Medication Administration Record (MAR), R1 centrally ordered medication, and the destruction report shows that on May 5, 2024, R1 still had medication and was given to R1. On May 10, 2024, R1 medication was given to R1 family member. On May 26th, 2024, the facility made a refill to Omnicare Pharmacy, and Omnicare refilled R1 medication on 6/19/2024. Report continued on LIC 9009c… Unsubstantiated Allegation: Staff are not properly trained to administer medications - UNSUBSTANTIATED It was alleged that the Staff are not properly trained to administer medications. However, during the investigation, LPAs reviewed the Med Tech schedule for May, June, and July 2024. S2, S7, S8, and S9 were scheduled as Med Tech during May, June, and July 2024. The record reviewed shows that S2, S7, S8, and S9 have all completed their training on record. Allegation: Lack of supervision resulting in resident sustaining a fall - UNSUBSTANTIATED It was alleged that the facility lacks supervision, resulting in a resident sustaining a fall. During the investigation, LPAs reviewed the R2 physician report, R2 assessment, the time R2 moved in and after the sudden fall. At the time of the incident, R2 was receiving appropriate supervision according to the R2 assessment. R2 assessment dated 12/17/2023 – 5/23/2024 shows R2 ambulates independently. R2 had a sudden fall on 6/24/2024 facility updated R2's needs and services plan after the fall, dated 6/25/2024, indicated that R2 will be checked every two hours before and after bedtime on going. Allegation: Facility is not ensuring a staff is on duty on the premises overnight- UNSUBSTANTIATED It was alleged that the facility is not ensuring a staff in on duty on the premises overnight. During the investigation, LPAs reviewed the staff schedule for May 2024 to the current shows the facility has staff on duty on the premises overnight. LPAs conducted staff and resident interview confirmed that there are staff on duty on the premises overnight. 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 and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 14, 2025 · control 15-AS-20250610084817

Type of visit: Required - 1 Year

On 07/14/2025 at 10:30 AM, Licensing Program Analysts (LPAs) P. Manalo and K.Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Marie Lagasca-Cruz, and explained the purpose of the visit. LPA toured the facility inside and out including but not limited to 7 residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 73 degrees F. The hot water temperature in a sample of residents’ shared bathroom were measured at 118.4, 112.9, 111.3, 116.6, 115, and 114.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid shower pan. Smoke detectors and carbon monoxide detector were in operating condition during visit. Alarm System Inspection was last conducted on 04/02/2025. Fire extinguisher was last serviced on 11/29/2024. Emergency Disaster Plan was last posted on 10/22/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 06/24/2025. At 12:46 PM, LPA reviewed 6 residents records. At 1:30 PM, LPA reviewed 6 staff records and 6 of 6 are associated to the facility. At 2:30 PM, LPA reviewed two sample of residents’ medications. Continue to LIC809-C... Continue from LIC809... Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 07/22/2025: Liability Insurance Administrator Certificate THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 11:46 AM, LPA observed unlocked topical cream in R1's room. At 12:00 PM, LPA observed food not properly stored and labeled. At 3:29 PM, record review revealed that the facility did not have an updated physician's report for residents. The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with Executive Director. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 14, 2025

The state marks this report as 9 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: -Questionable death. -Staff are not assisting residents with bathing needs. -Residents are left in soiled clothing for an extended period of time. -Staff are not ensuring that residents have clean clothing. -Staff are not assisting residents with refilling their prescriptions.

On this day, May 29, 2025, at 11:15 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Executive Director (ED) Marie Lagasca-Cruz, and informed the reason for visit. During the course of investigation, the Department reviewed residents’ records and obtained copies of including but not limited to the following documents: LIC601 Identification and Emergency Information; LIC602A Physician's Report; doctor's orders of medications; LIC622 Centrally Stored Medication and Destruction Records; Medication Administration Records; shower schedules; hospice record; death certificate. ......continued on 9099C (page 2) Unsubstantiated Page 2 LPA obtained copies of staff schedules, LIC501 Personnel Records and resident roster. LPA also interviewed the following: staff (S1, S2) and former Executive Director (FED) on 11/28/23; resident’s family member (W1) on 12/05/23; R1 and R3’s family member (FM1) and staff (S3 and S4) on 5/27/25. Allegation: Questionable death. It was reported that resident (R1) passed away on 11/19/23 because the facility did not seek timely medical assistance. S1 stated when she went to R1’s room sometime between 11/06/23 and 11/08/23 and observed R1 pale and not responsive, she called 9-11. R1 was sent out and diagnosed with infection. Records confirmed R1 was sent out to the hospital. Records also showed R1 was placed on hospice on 11/10/23 with terminal diagnosis of cerebrovascular disease. Death certificate showed immediate cause of death as cerebrovascular disease, Parkinson’s disease, adult failure to thrive and no other significant conditions contributing to R1’s death. Based on information gathered, the allegation is closed as unsubstantiated. Allegation: Staff are not assisting residents with bathing needs. S1 stated that R2 has not been showered for a month. S2 indicated that bathing is included in the resident’s Care Plan and the frequency depends on the Care Plan. S3 and S4 stated they give bath to residents 2 times per week. FM1 stated she visited R1 and R3 when they were at the facility and stated R1 and R3 were bathe 2 times per week. Review of bathing schedules showed R1 on the list on a once-a-week schedule. R2 was listed on twice-a- week schedule. LPA was not able to interview R1 and R3 due to these residents were no longer at the facility when complaint was received. Due R2’s medical diagnosis, LPA was also unable to obtain information. LPA tried to reach R2’s responsible person but was unsuccessful. Therefore, the allegation is unsubstantiated. .......continued on 9099C (page 3) Page 3 Allegation: Residents are left in soiled clothing for an extended period of time. S1 stated that R2 was often left in soiled clothing for hours and not provided care due to R2 has been deemed by the caregivers as a difficult resident. S1 also stated that when she was assigned to Memory Care, she observed R2 wore the same clothes from previous day. S2, S3 and S4 stated residents’ clothing are changed every day. FED stated that it was never brought to his attention about the issue. FM1 stated she never observed R1 and R3 in soiled/uncleaned clothes. W1 also stated not observing her mother in soiled clothing and when her mother felt wet, the caregiver came right away. LPA was not able to interview R1 and R3 due to these residents were no longer at the facility when complaint was received. Due R2’s medical diagnosis, LPA was also unable to obtain information. LPA tried to reach R2’s responsible person but was unsuccessful. Therefore, the allegation is unsubstantiated. Allegation: Staff are not ensuring that residents have clean clothing. S1 stated there were times she observed R2 not wearing undergarment and socks. S1 further stated that when she asked the caregivers, she was told that R2 did not have clean clothes. S2 stated there was never an incident where resident run out of clean clothing. S2 further stated that if they see residents do not have enough for the week, they communicate. S3 and S4 stated that residents assigned to them never run out of clean clothes. FED stated the issue was never brought to his attention. FM1 and W1 stated their love one never run out of clean clothes. LPA was not able to interview R1 and R3 due to these residents were no longer at the facility when complaint was received. Due R2’s medical diagnosis, LPA was also unable to obtain information. LPA tried to reach R2’s responsible person but was unsuccessful. Therefore, the allegation is unsubstantiated. ......continued on 9099C (page 4) Page 4 Allegation: Staff are not assisting residents with refilling their prescriptions. S1 stated that R2 and other residents were missing medications because the medications were not refilled. S1 further stated that according to S5, R2 was not receiving medications because R2's responsible person (FM2) was not picking up the phone when they call. S2 stated the med-techs are in-charge of medications including refills. S2 further stated that the cycle of med refills is every 2nd of the month to ensure residents never run out of medications and that 15 days before medications run out, the med-tech take care of refills. S3 and S4 stated the med-techs are in-charge of medications. W1 stated her mother never run out of medications and that the staff were very good in calling and telling her when her mother is running out of medications and refills were done right away. LPA tried but unable to obtain information from S5 and FM2. Therefore, the allegation is unsubstantiated. Based on interviews and records review, the five allegations are closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, May 29, 2025 · control 15-AS-20231122143232

Allegation investigated: -Resident sustained unexplained bruising while in care. -Resident is not provided a pendant. -Facility does not have an administrator during hours of operation.

On this day, 4/24/25, at 2:30 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegations and close the complaint. LPA met with Sales Director Tristan Reyes and Resident Services Coordinator Popotafea Aumua. Executive Director (ED) Marie Lagasca arrived at around 3:10 p.m. LPA informed the reason for visit. During the course of investigation, LPA obtained copies of resident rosters and staff schedule, and conducted interviews. LPA also obtained copies of the following residents' documents: LIC601 Indentification and Emergency Information; Admission Agreements; LIC602A Physician's Reports; Residents' Assessments; Unusual Incident Report (UIR); facility notes and Narrative Charting for resident. LPA interviewed the following: staff (S1 and S2) on 2/13/23; staff (S3, S4 and ED) on 4/24/25; residents (R3 and R4) on 4/24/25 ....continued on 9099C (page 2) Unsubstantiated Page 2 Allegation: Resident (R1) sustained unexplained bruising while in care. R1's family member (FM) stated that on 5/10/22, FM reached out to the assistant director regarding an incident where R1 ended up crying at the end of R1's shower and the next day the nurse found bruising on R1's shoulder and arms. LPA reviewed the documents from Pine Park Health, a third party that provides medical services to the residents in the facility. Pine Park's records and visit notes for R1 from 1/26/22 to 6/22/22 didn't show any note indicating R1 had bruising. Facility's Narrative Charting of communication with R1's responsible person and R2 (R1's husband) for R1 for 1/10/22, 1/13/22, 1/29/22, 2/16/22, 2/22/22, 3/14/22, 3/30/22 and 6/15/22 had no information pertaining to bruising. There's no UIR regarding bruising. LPA could not interview R1 and R2 since they were longer at the facility. Based on information gathered and LPA unable to obtain information from R1 and R2, the allegation is closed as unsubstantiated. Allegation: Residents not provided a pendant. FM stated that R1 and R2 did not have pendant for 4 days because it was broken. S1 and S2 stated R1 and R2 had pendant. S1 stated she does not recall R1 and R2 not having pendant for days. S2 stated it's always R2 who pressed the pendant when help was needed. S3 and S4 stated the residents in Assisted Living (AL) are provided pendants but not the residents in Memory Care (MC). When pendant is not working or broken, it is replaced same day. These statements were confirmed by LPA with ED. ED stated only residents in AL are provided pendant. ED further stated that residents in MC are not given pendants because staff do more supervision. If the pendant is broken, it is replaced the same day. The facility has at least 6 extra pendants. .....continued on 9099C (page 3) Page 3 R3 and R4 stated they have pendants. R3 stated she seldom use hers while R4 stated the pendant is working and the staff check it regularly. Based on information obtained and LPA unable to obtain information from R1 and R2, the allegation is closed as unsubstantiated. Allegation: Facility does not have an administrator during hours of operation. When LPA conducted an initial complaint visit on 6/24/22, LPA met with interim Administrator Mandy Taylor. Ms. Taylor has valid administrator certificate. S1 stated never was a time where facility has no executive director (ED)/administrator. If the ED quits and the corporate is in the process of hiring, the Regional Director serves as interim administrator. S2 stated the facility has always administrator to talk to. R3 and R4 stated there's always administrator and staff available. Based on information obtained and LPA unable to obtain information from R1 and R2, the allegation is closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Apr 24, 2025 · control 15-AS-20220607084551

Allegation investigated: Staff does not respond to call button in a timely manner. Facility does not have sufficient food available for their anytime menu. Staff does not treat residents with dignity. Staff would retaliate against residents who complaint of facility services. Facility is not providing nutritional food resulting in resident loosing weight. Insufficient staffing Resident is paying for services that's not being provided. Facility is not following resident's diet per doctor's order.

On 1/16/2025 at 11:35AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver complaint findings for the allegations above. LPA met with Executive Director, Marie Lagasca-Cruz. During the investigation, LPA interviewed 5 residents, 8 staff, witness, and complainant. LPA obtained and reviewed documents including admission agreement, emergency information, diet order form, care plan, physician's report, call button logs, monthly bills, and resident detail ledger. Staff does not respond to call button in a timely manner. Majority of the call button logs were missing the response time. Interview with residents revealed that staff respond to call button timely. Interview with staff indicated that staff would respond to call button within 10-15 minutes. S6 stated that sometimes caregivers would forget to clear the call after assisting the resident. (Continue on LIC9099C...) Unsubstantiated Facility does not have sufficient food available for their anytime menu. Interview with residents revealed that they are able to order from the "Always Available Menu". Interview with staff indicated that sometimes food distributors would be out of stock on certain food items on that menu. LPA observed facility have sufficient perishable and nonperishable items available. Staff does not treat residents with dignity. Interview with residents and staff revealed that staff treat residents well and are friendly to residents. Residents stated they have not witness staff mistreat residents. Staff would retaliate against residents who complaint of facility services. Interview with residents revealed that staff did not retaliate against residents. Interview with staff indicated they have not witness staff retaliate against residents and would treat residents the same. Facility is not providing nutritional food resulting in resident loosing weight. Interview with staff indicated the facility provides nutritional foods to residents and was not aware any residents loose weight due to poor nutrition. There was a lack of information provided regarding the resident who loose weight due to not provided enough nutritional foods. Insufficient staffing Interview with staff indicated the facility has sufficient staffing which includes 2-3 staff for morning and afternoon shift, and 2 staff for night shift. Interview with residents revealed that majority of residents felt the facility had enough staff. Resident is paying for services that's not being provided. R1's care plan indicated that R1 needed standby assist with bathing, partial assist with transfers, escort R1 to meals/activities, and special diet which was a level 4 care. However, R1's detail ledger revealed that R1 was charged for level 2 care which did not include most of the services in R1's care plan. (Continue on LIC9099C...) Facility is not following resident's diet per doctor's order. R1 had a diet order form which indicated that R1 is on a mechanical soft diet. Interview with staff revealed that residents with special diets are identified in the kitchen area. S3 stated that staff have provided mechanical soft meals for R1, but R1 didn't want the food and sent it back. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore these allegations are UNSUBSTANTIATED. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Jan 16, 2025 · control 15-AS-20230925101546

Allegation investigated: -Resident (R1) in care sustained unexplained medication overdose. -Resident (R1) became severely dehydrated while in care.

On this day, 1/09/25, at 11:15 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Executive Director (ED) Marie Lagasca-Cruz, and informed the purpose of visit. During the course of investigation, the Department obtained copies of the following resident documents: medical records; LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; Pre-placement Appraisal; Care Plan; facility notes; doctor's order of medications; Medication Administration Records. Staff (S1, S2, S3, S4, S5, S6) were interviewed on 3/09/23, 3/27/23, 4/13/23 and 4/17/23 and family members (FM1 and FM2) on 3/09/23. R1 was also interviewed on 3/23/23 and previous Assistant Executive Director on 4/13/23. .....continued of 9099C (page 2) Unsubstantiated Page 2 Allegation: Resident (R1) in care sustained unexplained medication overdose. FM1 stated that R1 was admitted to the facility on 1/10/23. On or around 1/15/23, S1 called FM1 and informed FM1 that R1 was refusing to eat and participate in activities. Approximately 4 to 5 days after admission, FM2 received a call from facility staff saying R1 was not eating, drinking, or getting out of bed. FM2 stated that on or around 1/20/23, FM1 and FM2 received a call from S1 informing that R1 will be send out to the hospital. Prior to arrival to the hospital, the Emergency Department (ED) doctor called and told FM1 and FM2 that R1 was poisoned by Lithium and that R1 was dehydrated. Medical records showed R1 was brought into the hospital on 1/21/2023 with Lithium toxicity and an acute kidney injury. The lithium toxicity caused R1 to have an altered mental status while the acute kidney injury was caused by poor food/fluid intake. R1 refused to take her medications at various times on 1/13/2023, 1/14/2023, 1/19/2023 and 1/21/2023. Staff who were interviewed all stated R1 refused to do anything, refused to get out of bed and refused to eat and drink throughout her stay at the facility. Resident Services Director (RSD) assessed R1 at home prior to R1’s admission and R1 was independent and able to do a lot of things on her own. However, after R1’s admission, R1 changed, became depressed and only wanted to stay in bed. R1’s refusal to get out of bed, eat and drink and do anything contributed to her condition leading her to be hospitalized. R1 stated she had been taking Lithium for over 5 years. R1 admitted not eating and stated that staff brought food to R1’s room and tried to be feeding her but does not remember if she drank fluids regularly while at the facility. The medical records confirm that R1 was admitted for lithium toxicity. The medical records do not indicate a cause, however, FM1 stated that lithium must be accompanied by adequate liquid intake, otherwise it accumulates in the body. Staff reported that R1 was not eating and drinking regularly. It was found that R1 had medication orders for the lithium and the facility’s Centrally Stored Medication and Medication Administration Records were in order. The facility med-tech stated having provided all medications as ordered by the primary care physician (PCP). Therefore, the allegation is unsubstantiated. ....continued on 9099C (page 3) Page 3 Allegation: Resident (R1) became severely dehydrated while in care. All staff interviewed stated R1 refused to eat and drink during the 11 days R1 resided at the facility. R1 had two sips of an 8 ounce cup of water when her medication was administered to her. Staff noticed that R1’s water cup and water pitcher were barely touched. R1 drank juice that was offered to her and ate approximately 15%-25% of food that was served to her. All staff stated having made attempts to encourage R1 to eat and drink during her meals, even feeding her. R1’s refusal to eat and drink contributed to her worsening condition. Staff noticed R1 had cracked lips and was not eating or drinking much. They knew R1 needed water/fluids for her medications. R1 stated she had been taking Lithium for over 5 years. R1 also stated that Lithium is a form of salt and taking this medication would require one to drink a lot of water to have it released from one’s body. R1 admitted to not eating and drinking consistently and stated that staff brought food and liquid to R1’s room and tried feeding her but does not remember if she drank fluids regularly while at the facility. No information emerged to indicate that staff were not attempting to have R1 drink liquids. Therefore, the allegation is unsubstantiated. Based on records review and interviews, both allegations are unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No citation issued. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Jan 9, 2025 · control 15-AS-20230209091605

Type of visit: Case Management - Deficiencies

On this day, 1/09/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit resulting from a complaint (Complaint Control # 15-AS-20230209091605) investigated by the Department. LPA met with Executive Director (ED) Marie Lagasca-Cruz, and informed the purpose of visit. During investigation, the Resident Services Director (RSD) stated she advised R1’s sister via telephone on 1/14/23 that R1 was not well and was going to send her to the hospital. Between 1/14/23 through 1/21/23, R1 was weak, refused to eat on some days, and barely able to stand up. Other days, R1 was responsive and requested foods but ate very little. During RSD’s interview, RSD stated R1’s sister declined to have R1 sent to the hospital, but RSD did not agree. Previous Assistant Executive Director stated staff are to report concerns to the resident's doctor when families decline. There was no communication with R1’s doctor for the date of 1/14/2023, and R1 was not sent to the hospital until 1/21/2023 – a week later. Deficiency is cited per Title 22 California Code of Regulations, and listed on LIC809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Jan 9, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Jan 10, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility......... (2) The licensee shall provide assistance in meeting necessary medical and dental needs……... -This requirement is not met as evidenced by: -Based on records review and interviews, the licensee did not comply with the section in not seeking immediate medical assistance for resident (R1) which posed an immediate risk to the health risk to person in care.the state’s words, verbatim · CDSS document, Jan 9, 2025

Plan of correction: Executive Director to in-service the staff and submit copy of training topic with attendees signatures by 1/10/25.

Allegation investigated: Facility charged resident for services that were not provided

On 12/9/2024 at 1:45pm, Licensing Program Analyst (LPA), K. Nguyen arrived unannounced to delivered finding for the above allegation. LPA met with Executive Director, Marie Lagasca- Cruz and explained the reason for the visit. Allegation: Facility charged resident for services that were not provided- Unsubstantiated During the investigation LPA interviewed staff and collected/reviewed billing/services records. It was alleged that Facility charged resident for services that were not provided, however after recorded reviewed and interviewed. Facility have dropped all the charges from RP, and all services that are being charged is correct. S1 stated R1 responsible party do not owe the facility anything because the facility has dropped all charges. Report Continued on LIC 9099c... Unsubstantiated 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 and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 9, 2024 · control 15-AS-20241112091534

Allegation investigated: Staff did not notify resident's authorized person of injury

On 12/6/2024 at 10:00am, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Marie Lagasca-Cruz and explained the reason for the visit. During the course of the investigation the Department conducted interviews with staff, witness, and obtained and reviewed records, including medical records from Kaiser of San Leandro for R1. Allegation: Staff did not notify resident's authorized person of injury During interview with W1 it was stated that the facility did not become aware of R1’s fall until W1 spoke with former staff (S2). Department reviewed incident report that was Continued on LIC9099C. Substantiated Continued from LIC9099. submitted to CCLD, which indicated R1 had complained of pain to his arm to his family member on 3/18/2022, where R1 slid from his chair onto the floor. Per incident report R1 stated the incident occurred two weeks prior. R1 also stated at the time of the incident he refused help from the two (2) staff that came to assist. S1 stated during interview that protocol is for staff to inform the director of the incident in a timely manner. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights and this report provided. Continued from LIC9099. and fell when trying to independently transfer from bed to wheelchair. Review of Kaiser of San Leandro medical records dated 3/19/2022, indicated R1 sustained a fracture to his right humerus bone while transferring from his wheelchair to his bed. At the time of admittance to the facility and at the time of the injury, R1 was independent and able to transfer between his bed and wheelchair. Based on record review, R1 was listed as ‘independent’ and did not require transfer assistance from and to bed from the wheelchair. Allegation: Staff did not ensure that resident was adequately fed W1 stated that R1 was able to wheel himself around but didn’t want to. R1 wanted staff to wheel him downstairs to the dining area. W1 stated there were times that staff would come to assist R1, but it was too early for R1 to eat. Department reviewed charting notes from facility that indicated R1 refused dinner several times due to R1 had food or snacks in his room. Per R1's assessment R1 required reminders for meals not to be escorted. Allegation: Staff did not provide resident showers according to the resident's Admission Agreement Based on interview with W1 showers were to be given to R1 Friday’s at 1pm and R1 would refuse if showers were not timely. W1 stated the facility was aware of this before R1’s admission. Review of admission agreement indicated facility will provide assistance with bathing. Review of R1's assessment dated 11/29/2021 indicated R1 required a one (1) person assist per week for bathing. Department did not Continued on LIC9099C. Continued from LIC9099C. observe any documentation that was agreed upon between R1's responsible party and the facility that showers will be given at a specific time. Per S1 staff would try to accommodate R1's request for the time of shower but it was not always possible due to assisting other residents. Allegation: Staff did not keep resident's room clean or sanitary Based on initial interview with W1 staff did not keep resident’s room clean or sanitary. During interview with W1 on 12/2/2024, W1 stated there was not an issue with R1’s room being cleaned. W1 saw the housekeeper a few times while visiting. Allegation: Facility call system was not accessible to resident Based on interview with W1 the call pendent R1 was given was usually broken. W1 stated when the pendent wasn't working staff would come and take it, but wouldn't get it replaced for a couple of days. During interview with S1 if a pendent was not working or low battery the system will notify staff and a new pendent will be give. S1 stated the pendents can not be fixed. The facility keeps pendents available. S1 pulled a call log from the archives dated 3/13/2022 - 3/31/2022, which divulged R1 had used pendent six (6) times during that period. The dates the pendent was used was 3/13, 3/14 (2xs), 3/16, 3/17, and 3/18. Based upon the interviews conducted and information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Dec 6, 2024 · control 15-AS-20240124152114

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Dec 13, 2024

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within 7 days of the occurrence... evidence by: This requirement was not met as evidence by: Based on interview and observation the Licensee did not comply with the section cited above by notifying the responsible party, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 6, 2024

Plan of correction: Administrator submitted reporting and abuse training that was completed on 7/27/2024, to LPA during visit. Deficiency cleared during visit.

Type of visit: Case Management - Deficiencies

On 10/21/24 at approximately 2:15 pm, Licensing Program Analyst (LPAs) K. Nguyen and L. Alexander conducted a case management visit pertaining to a letter received by the Oakland CCL ASC Regional Office from the facility. LPAs met with Executive Director(ED), Marie Lagasca and explained the purpose of the visit. On July 11, 2024, the Oakland CCL ASC Regional Office received from the facility a letter of intent to delicense the third floor of the physical plant and convert those units for Independent Individuals who are 55 years of age and older. The letter did not specifically request approval from CCL and had insufficient detail pertaining to how the co-mingling of Independent aged 55+ renters, and licensed RCFE Assisted Living residents, would be managed to ensure the Health & Safety of the Assisted Living residents. LPAs interviewed the ED, stated that the facility has not and are not accepting any independent living resident at this time. The ED informed the LPAs that the facility is advertising for 55+ independent persons but nit accepting any for residency, per need for approval from CCL. On 10/16/24 LPM Jeremy Fong and on 10/21/24 LPA Kelly Nguyen and ED confirmed that the facility’s website is advertising for independent renters aged 55 and older, which constitutes a change to the Plan of Operation without having obtained approval from Community Care Licensing. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 21, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208 · Plan of correction due date: Nov 4, 2024

“…Any significant changes in the plan of operation…shall be submitted to the licensing agency for approval." This requirement is not met as evidenced by: Based on observations, interviews and record review, the licensee did not comply with the section cited above in by changing the plan of operation without CCLD approval which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 21, 2024

Plan of correction: By POC date, the facility will submit to CCLD for review a new, detailed plan of operation describing the changes that the Licensee wishes to implement.

Type of visit: Case Management - Other

On this day at around 2:10 pm, Licensing Program Analyst (LPA) K. Nguyen conducted a case management visit in connection with an 30-day termination notice of R1. LPA met with Resident Services Director, Marissa Baldomero and explained the purpose of the visit. LPA received an 30day termination notice in regrade of R1 not being able to pay. R1 is still reside at the facility. S1 stated R1 have not pay the facility since February 2024. The letter indicated that the notice effective date is June 14, 2024, due to the outstanding amount of 7,321.67. S1 stated that R1 family is aware of the situation, and family didn’t say anything. R1 is not reserved, no POA, and R1 makes own decision, and R1 is the full payee. Facility is in the process of eviction but is waiting for the judge to make the final decision. S1 stated R1 told them R1 knows that R1 owe money but doesn’t want to pay, and is waiting to be evicted. No deficiency was noted during the visit. A copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 1, 2024

Type of visit: Case Management - Incident

On this day at around 1:10 pm, Licensing Program Analyst (LPA) K. Nguyen conducted a case management visit in connection with an incident reported by the facility. LPA met with Resident Services Director, Marissa Baldomero and Operation Specialist, Kathy Valencia and explained the purpose of the visit. LPA received an UIR dated on 9/17/24 regarding an elopement. LPA interviewed S1 stated on the day of the incident staff walked R1 on a daily routine to visit R1 wife (lunch and dinner). R1 decided to take a walk and R1 wife cannot stop R1 from taking a walked. After R1 took off the wife called the front desk and informed us that R1 had taken a walk. S1 stated that this is a new behavior for R1 to walked off from R1 wife apartment. S2 stated that it was an agreement between the family and the facility to have R1 visit his wife on a daily routine. After R1 wife informed us we immediately send out staff to search for R1 and found R1 near senior center. S2 stated that the care plan has been update to R1 wife go to visit R1 in memory care. S1 stated that R1 wife stay in Assisted Living so when R1 took off there was no alarm that went off, due to assisted living unit. S2 is keeping a close communication with R1 family members. No deficiency was noted during the visit. A copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 1, 2024

Allegation investigated: Staff are charging resident for services not rendered

On 8/23/2024 at 11:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver complaint findings for the allegation above. LPA met with Memory Care Director, Marissa Baldeomero. During the investigation, LPA interviewed 3 residents and 3 staff. LPA obtained and reviewed documents (admission agreement, emergency information, care plan, physician's report, resident assessments, and resident detail ledger). Resident assessment dated 11/10/2022 indicated that resident (R1) was a level one (1) for care. However, R1's detail ledger revealed that R1 was charged for level three (3) care for dates after 11/10/2022. Based on LPA information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Exit interview conducted. A copy of this report and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 23, 2024 · control 15-AS-20230613112652

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a) · Plan of correction due date: Sep 6, 2024

Additional Personal Rights of Residents in Privately Operated Facilities. 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... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by charging R1 for services not rendered which poses a potential personal rights violation to the persons in care.the state’s words, verbatim · CDSS document, Aug 23, 2024

Plan of correction: Facility has agreed to update R1 detail ledger and refund R1 for the difference according to the updated detail ledger if necessary. Facility will submit the updated ledger to CCLD by POC date.

Allegation investigated: Sexual abuse

On 7/31/2023 at 9:00am, Licensing Program Analyst (LPA), K. Nguyen arrived unannounced to conduct investigation for the above allegation. LPA met with Jeralyn May, Interim Administrator (AD), and explained the reason for the visit. Allegation: Sexual Abuse- Unsubstantiated During the investigation LPA interviewed staffs, Resident (R1), and collected/reviewed records. LPA collected the following for Resident (R1): Physician report, MAR, need and services plan, and facility charting log. Report continued on LIC 9099c... Unsubstantiated LPA interviewed R1, R1 stated R1 does not recall the time frame of the event. R1 stated that nothing happened to R1. LPA interviewed S1, S2, S3, S4, S5, and S6 all indicated that they noticed that R1 memory have be declining alot and is on a lot of medication that might cause R1 to hallucinate. S6 stated that the polices officer spoke to S6 whom was investigating this incident indicated that he believes/ observed that R1 is hallucinating, because R1 is telling two different stories, and R1 doesn’t remembered. 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 and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 31, 2024 · control 15-AS-20240726132539

Type of visit: Case Management - Deficiencies

On this day at around 3:00 pm, Licensing Program Analyst (LPA) K. Nguyen conducted a case management visit in connection with an incident reported by the facility. LPA met with Administrator, Jeralyn May and explained the purpose of the visit. LPA interview S1 regrading the incident. S1 stated that the gate that was supposed to be lock was not lock that led to an elopement. During the time resident was led outside by Activity assistance for an activity. The staff didn’t notice that the resident had went outside the gate. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 25, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(j) · Plan of correction due date: Aug 8, 2024

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. -This requirement is not met as evidenced by: S1 stated that the gate that was supposed to be lock was not lock that led to an elopement. During the time resident was led outside by Activity assistance for an activity. The staff didn’t notice that the resident had went outside the gate.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Administrator will keep a record of staff that are checking the gate prior to bringing residents outside the yard. Administrator will conduct an in-service training topic: Elopement in Dementia with all the staff signature and submit to CCLD by POC date.

Type of visit: Case Management - Deficiencies

While LPA K. Nguyen was at the facility for a one annual inspection, the following deficiency were observed. After touring the memory care unit, LPA observed residents where being lock inside their room. In memory care unit there is a door that is lock cannot open without the key. That door led to the resident door that is looked as well. LPA observed that the resident was being locked inside, while still eating breakfast. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 25, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Jul 26, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for locking residents inside their room in memory care unit.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Administrator will unlock all the residents room in memory care. In service training of all staff in memory care will sign off that they understand the regulation under resident personal rights.

Type of visit: Required - 1 Year

On 07/25/2024 at 9:00APM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced annual 1-year required inspection. LPA met with Administrator Jeralyn May. The facility’s fire clearance was approved for one hundred (100) ambulatory/non-ambulatory residents. LPA toured the facility including but not limited to apartments, bathrooms, kitchen, common area, and back yard. The facility consists of 74 total apartments. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for residents is maintained at 71 degrees Fahrenheit. LPA observed lighting in rooms are adequate for the comfort and safety of the residents. Hot water temperature in the shared bathrooms was measured at 110.6 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-days of non-perishables and 2-days of perishables foods. Smoke detectors/carbon monoxide were in operating condition during visit. Sprinkler system was last serviced on 11/1/2023. Fire extinguisher was last services on 12/6/2023. Fire drill last conducted 01/01/2024. First aid kit was observed to be complete. At 1:30pm LPA reviewed 5 out 5 staff do not have First Aid nor CPR on files. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 25, 2024

Type of visit: Case Management - Other

LPA K. Nguyen conducted an unannounced case management visit to serve an immediate exclusion order to staff S1. LPA K. Nguyen first spoke privately with Executive Director Rob Roby to explain the situation - providing him with a copy of the Order to Executive Director of Immediate Exclusion. According to Executive Director S1 haven’t been at the facility since May 16, 2024, also is terminated from our facility. LPA K. Nguyen reviewed this report with Executive Director, and a copy of this report is provided via email.the state’s words, verbatim · CDSS document, Jun 17, 2024

Type of visit: Required - 1 Year

On 01/27/2024 at 1:30PM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced annual 1-year required inspection. LPA met with Robert Roby Administrator, The administrator currently holds a certificate (#6066101740) that expires on 5/10/2025. The facility’s fire clearance was approved for one hundred (100) ambulatory/non-ambulatory clients. LPAs toured the facility including but not limited to apartments, bathrooms, kitchen, common area, and back yard. The facility consists of 74 total apartments. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degrees Fahrenheit. LPA observed lighting in rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared bathrooms was measured at 119.2 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-days of non-perishables and 2-days of perishables foods. Smoke detectors/carbon monoxide were in operating condition during visit. Sprinkler system was last serviced on 11/1/2023. Fire extinguisher was last services on 12/6/2023. Fire drill last conducted 01/01/2024. First aid kit was observed to be complete. Continued on LIC809C. Continued from LIC809. LPA observed the following deficiencies: · At 1:37pm, LPA observed Lysol and grease express located in a unlocked cabinet in the unlocked laundry room. · At 3:20pm, LPA observed staff files not assessable. Eight (8) of Sixty-Six (66) resident records were reviewed and all were found to be complete. The following forms to be updated and submitted to CCLD by 02/2/2024: Resident Roster · LIC 308 Designation of Administrative Responsibility · LIC 309 Administrative Organization · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan (9 pages) · Liability Insurance The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 27, 2024

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Facility has mold

On 12/11/2023 at 11:00 AM, Licensing Program Analyst P Watson arrived unannounced deliver findings for the above allegation. LPA met with Executive Director Robert Roby and explain the purpose of the visit During the course of the investigation, LPA toured the facility and interviewed staff and residents, and obtained resident roster with family contact information. LPA also reviewed documentation regarding mold inspects done at facilty. Report continues on 9099 C Substantiated It was alleged that Staff did not provide a safe and comfortable environment Based on observations, LPA observed the facility to be safe and comfortable for residents. Based on interviews with residents (R1, R2 and R3) residents felt that they were safe and comfortable, residents stated they have had no issues with staff and that staff are very nice. Based on interviews with staff (S1) residents have not expressed feeling unsafe or uncomfortable. S1 stated that they have not observed a resident being treated unwell and that staff ensure to take care of the residents. Based on LPA observations, interviews, 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 and a copy of this report provided. It was alleged that Facility has mold Based on interview with Maintenance Manager (MM), if mold/mildew was present and reported to facility staff it would be treated in house. MM stated that they would inspect the area, relocate the resident residing in area and treat it with cleaners such as bleach. Based on documentation review, there was evidence of mold located in a resident’s apartment and mold treatment was required. Based on interviews with staff (S3 and S4) mold has been observed in various apartment’s in residents AC units and closets by staff and residents residing. S3 stated that they have reported their observations to facility management and noticed AC units were replaced recently. S3 believes mold is throughout the facility still despite facility management changing AC units. Based on LPAs interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 11, 2023 · control 15-AS-20231002093949

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 20, 2023

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by: Based on interviews and documentation review the facility has/had mold in various resident apartments which poses/posed an immediate/potential Health, Safety or Personal Rights risk to persons in carethe state’s words, verbatim · CDSS document, Dec 11, 2023

Plan of correction: Administrator will submit their mold treatment plan and prevention plan to ensure no mold outbreak in the future to CCL by POC date

Type of visit: Case Management - Incident

On this day at around 3:05 pm, Licensing Program Analyst (LPA) Luisa Fontanilla conducted a case management visit in connection with an incident reported by the facility. LPA met with Executive Director Robert Roby and explained the purpose of the visit. During the visit, LPA obtained Resident 1 (R1) Physician's Reports, Needs and Services Plan and Hospital discharge papers . LPA reviewed records and interviewed Staff 2 (S2) and Resident 1 (R1). Based on R1's Physician's Report (PR) dated 9/22/2022, R1 is able to bathe/dress and feed self and is able to transfer to and from bed. Resident assessment dated 10/6/2022 indicates R1 ambulates independently with or without assistive device. S2 states R1 ambulates independently. In a previous interview conducted with Memory Care Director, Director states R1 ambulates independently. No deficiency was noted during the visit. A copy of this report was provided to Roby.the state’s words, verbatim · CDSS document, Dec 6, 2023

Allegation investigated: Facility staff did not ensure the resident file was up to date.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a 10-day complaint visit. LPA met with Executive Director (ED) Robert 'Rob' Roby and informed the reason for visit. LPA obtained copies of resident roster, conducted interviews, and reviewed resident records. It was alleged that when staff contacted 911 there were just blank pages in the emergency binder for residents so staff could not provide accurate information to the first responders. LPA interviewed 2 staff (S1 and S2) who stated when 911 is called, the facility has emergency binder that contains document for the resident which is provided to the first responder. According to S2 the emergency binder contains residents' Face Sheets, information including doctor's order of medications, insurance, and resident's diagnosis. ....continued on 9099C Substantiated LPA selected 4 residents from the roster and reviewed their records. LPA observed 3 of the 4 residents do no have records on the emergency binder. The ED also checked the emergency binder and didn't see any documents for the 3 residents. Based on information gathered, the preponderance of evidence is met, therefore. the allegation of facility staff did not ensure the resident file was up to date is closed as substantiated. Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.the state’s words, verbatim · CDSS document, Nov 28, 2023 · control 15-AS-20231122143232

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Dec 12, 2023

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 is not met as evidenced by: -Based on records review and interviews, the licensee did not comply with the section above for not having records in the emergency binder for 3 out of 4 residents which pose potential health and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Nov 28, 2023

Plan of correction: Executive Director to check the emergency binder and have the documents completed for all residents, Self-certification to be submitted by 12/12/2023.

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

Type of visit: Case Management - Health Checks

On this day, November 28, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 1 complaint (Complaint # 15-AS-20231122143232). LPA met with Executive Director (ED) Robert 'Rob' Roby and Assisted Living Director Shenina Robinson-Mason. LPA toured the facility including but not limited to common areas, dining rooms, medication room, activity rooms/areas, and bathrooms on the first and second floors. LPA observed the medication room open and attended by a med-tech. LPA randomly selected for inspection a total of 5 resident rooms on the first and second floors. During review of 4 residents records, LPA observed no Death Report and Unusual Incident Report (UIR) for 1 of the residents. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties. Deficiencies were discussed with ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Nov 28, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Dec 12, 2023

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency....(1) A written report shall be submitted to the licensing agency ... within seven days of the occurrence of any of the events......(A) Death of any resident from any cause regardless of where death occured -This requirement is not met evidenced by: -Based on record review, the licensee did not comply with the section above for not submitting the death report within 7 days which posed potential personal rights risk to person in care.the state’s words, verbatim · CDSS document, Nov 28, 2023

Plan of correction: Corrected. Executive Director provided copy of Death Report while LPA is at the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Dec 12, 2023

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency....(1) A written report shall be submitted to the licensing agency ... within seven days of the occurrence of any of the events.....(D) Any incident which threatens the welfare, safety or ........ ......health of any resident...... -This requirement is not met evidenced by: -Based on record review, the licensee did not comply with the section above for not submitting an incident report within 7 days which posed potential personal rights risk to person in care.the state’s words, verbatim · CDSS document, Nov 28, 2023

Plan of correction: Corrected. Executive Director provided copy of incident reportt while LPA is at the facility.

Allegation investigated: Staff consumed alcohol while on duty.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Executive Director (ED) Robert 'Rob' Roby and informed the reason for visit. LPA obtained copies of resident roster, staff schedule and staff contact information. LPA interviewed the ED and staff (S4 and S5). ED stated he came to the facility early morning on October 18, 2023 and observed 3 staff (S1, S2 and S3) in the library with opened cans of beer. One of the staff confirmed that the ED came in that early morning while the other one indicated she learned about the alcohol drinking after it happened. ......continued on 9099C Substantiated Based on information obtained, the preponderance of evidence is met, therefore. the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided. Based on information obtained, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that a violation occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Oct 23, 2023 · control 15-AS-20231020093333

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 6, 2023

87468.2 Additional Personal Rights .... (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All 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 is not met as evidenced by: -Based on interviews, the licensee did not comply with the section above when staff consumed alcohol while in the facility which posed a potential safety and/or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 23, 2023

Plan of correction: ED stated the 3 staff were terminated. In addition, ED to in-service the staff. and submit copy of training topic with attendees signatures by 11/06/23.

Type of visit: Case Management - Deficiencies

On 10/4/2023 at 4:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Executive Director, Robert Roby. While LPA G. Luk was at the facility for a complaint investigation (#15-AS-20230925101546), the following deficiencies were observed. After touring the kitchen, LPA observed chemicals for floor repairs were stored in the kitchen area. Staff removed the chemicals and put them with other cleaning supplies room. At around 4:45PM, LPA observed a tray of bacon was stored in the walk-in refrigerator without any covering/wrapping. LPA observed other containers with loosely covered wrappings. Staff discard bacon during inspection. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 4, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(24) · Plan of correction due date: Oct 5, 2023

General Food Service Requirements. Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas... This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by storing chemicals in the kitchen area which poses an immediate health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: Staff removed the chemicals to the cleaning supplies room during inspection. Deficiency cleared

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(23) · Plan of correction due date: Oct 20, 2023

General Food Service Requirements. All readily perishable foods... shall be stored in covered containers... This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by storing foods without covered container which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: Executive Director has agreed to conduct training with all kitchen staff regarding storing food items and submit staff sign-in sheet & materials to CCLD by POC date.