Park View Place

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Annual/Random

Licensing Program Analyst (LPA) S Vaid conducted the required annual inspection. LPA arrived unannounced and met with Claudella Farrow-receptionist who notified the administrator LeeAnn Hefner arrived shortly after and assisted with the tour. The facility is licensed to serve 142 non-ambulatory residents ages 60 and over, of which eight (8) may be bedridden, approval for twelve (12) hospices. There is an approved delayed egress for memory care. The building is a three-story building which was consisted of the front lobby, the memory care unit, common areas, resident rooms and private bathrooms, public bathrooms, dining rooms, central restaurant style kitchen, offices, housekeeping closets, activity rooms, bar area, beauty salon, theater room, laundry and linen storage and supply rooms, and medication rooms. LPA utilized the Compliance and Regulatory Enforcement tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and cleaning/disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Dementia Plan and training, and facility maintains the required liability insurance, expires 01/01/2027. CONTINUED ON 809C...... Physical Plant & Environment Safety: LPA toured facility, nine (9) residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested daily throughout the facility resident private restrooms and measured within the required range of 105-120 degrees. There is a shade patio and garden area for residents. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Dining staff uses approved menus and follow residents special diets. Walk-in fridge and freezers temperatures are measured and recorded daily. Special diets are provided to 35 residents requiring mechanical, soft, puree, low sodium and low sugar diets. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 9 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman posted in the front lobby and common areas. Planned Activities: Facility provides scheduled activities with a monthly calendar. There is an outdoor activity area available for the residents. LPA observed residents participating in planned activity. Staffing: There is always sufficient staffing in the facility. With night staff that are trained and able to assist in care and supervision of the residents in the case of an emergency. CONTINUED ON 809C.......... Personnel Records-Training: Staff have criminal record clearance, current First-Aid training along with training in postural support, assisted living, memory care, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 5 staff files with no issues observed. Administrator LeeAnn Hefner certificate expires on 03/29/2027. Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a Medication Room and are in their original containers. LPA reviewed medications for six (6) assisted living residents and three (3) memory care residents. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Fire and disaster drills are conducted unannounced monthly by third party company during different shifts. Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies. Facility admits residents with dementia and staff have all required training documented within personnel files. LPA observed rooms that have oxygen with the required signs posted. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to Executive Director, LeeAnn Hefner.the state’s words, verbatim · CDSS document, Aug 28, 2026

Allegation investigated: Staff do not maintain a comfortable temperature for residents in care.

On 08/06/26, Licensing Programming Analyst (LPA) Jewel Baptiste conducted a 10-day complaint investigation at the facility listed above. Upon arrival, LPA met with the concierge, Cladella Farrow, who contacted Leeann Hefner (Executive Director). At 9:55 a.m., the executive director arrived, and LPA explained the reason for the visit. During today’s visit, LPA obtained the resident roster, staff roster, JVAC invoice for January 2026 to August 2026, Email exchange from the Executive Director, and employee temperature logs dated February 2026 to August 2026. LPA interviewed the Executive Director and four (4) staff members, who shall be referred to as Staff #1 through Staff #4 (S1-S4). LPA also interviewed a total of ten (10) residents who shall be referred to as Resident #2 through Resident #11 (R2-R11). Due to R1’s medical diagnosis, LPA could not conduct an interview. LPA interviewed a Family member who shall be known as Witness#1(W1). LPA toured the facility with the Executive Director and inspected the 13 resident bedrooms affected by the HVAC system, namely rooms 124, 125, 126, 127, 221, 222, 223, 224, 315, 316, 317, 318, and 319. (Report continued on 9099C) Unsubstantiated The investigation reveals the following: Regarding " Staff do not maintain a comfortable temperature for residents in care," it is alleged that R1’s room is excessively hot and stuffy. According to the Executive Director, the facility's HVAC has been out of order, and 13 resident bedrooms have been affected. The issue started on February 21st, 2026, and the system was repaired on July 31st, 2026. Initially, parts were needed, and then other issues with the system arose. While the system was being repaired, the residents in the 13 rooms were given fans and portable air-conditioning units. The Executive Director stated that the residents had no issues; once they received the portable system, they had no complaints, and they were happy. The residents' bedrooms were also checked twice a day, with the temperature recorded and the type of solution received noted via temperature log. 4 out of 4 staff stated the HVAC system was down, but the residents' bedrooms were still comfortable due to the portable units or fans. They further stated they checked on the residents every 1-2 hours to ensure they were not affected by the temperature. 1 out of 10 residents were unable to answer LPA’s questions. 9 out of 10 residents stated that although there was an issue with the HVAC system, the facility ensured the temperature in their rooms was comfortable. They further confirmed that staff checked on them to ensure they were comfortable. LPA toured the facility and measured the temperature, which was between 78 and 85 degrees, within Title 22 regulations. The temperatures in the residents' bedrooms can be adjusted to their liking. LPA observed portable air conditioning units and fans in the residents' rooms. Via the log and LPA interviews, some residents refused fans and portable air conditioning units. LPA also reviewed the daily logs and confirmed that the resident bedrooms were between 70 and 85, while the HVAC system was being repaired. Residents in the rooms below 78 stated they preferred it that way. W1 stated that although there was an issue with the system, their family members were comfortable and happy due to the fans and the portable air conditioning units provided. Based on LPA's interviews, the investigation revealed that, although the allegation may have occurred or is valid, there is no preponderance of evidence to prove whether the alleged violation did or did not occur; the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Leeann Hefner, and a copy of this record was provided.the state’s words, verbatim · CDSS document, Aug 6, 2026 · control 28-AS-20260729201720

Allegation investigated: Staff are charging residents for services not provided

***This licensing report supersedes the previous licensing report dated 05/19/26 in order to clarify information obtained during the complaint investigation and to reissue the citation. The investigation findings will remain the same*** On today’s visit, Licensing Program Analyst (LPA) Vaid conducted a follow up visit and met with Executive Director (ED) LeeAnn Hefner. The purpose of the visit was discussed. On 05/19/2026, Licensing Program Analyst (LPA) Vaid conducted a subsequent visit for the above-mentioned allegation. LPA Vaid met ED Hefner and discussed the reason for the visit. LPA and ED Hefner toured the facility and did not observe any health or safety concerns. On 12/08/25, LPA Vaid conducted an unannounced 10-day initial visit regarding the allegations mentioned above. Met with ED Hefner and discussed the allegations. LPA Vaid requested, and obtained the relevant documents: Resident #1 and #2, face sheet/ID, pre-placement, medical/physicians report, needs and services, admissions agreement. Itemized Invoices for Memory Care charges for 6 months (June 2025 - November 2025). Four (4) residents files (face sheet/ID, pre-placement, physicians report, needs and services were requested and obtained. R1’s Admissions Agreement to be emailed to LPA for review. Continued on 9099C Substantiated ***This licensing report supersedes the previous licensing report dated 05/19/26 in order to clarify information obtained during the complaint investigation and to reissue the citation. The investigation findings will remain the same*** Regarding the allegation: Staff are charging residents for services not provided. It is alleged that the facility is charging a resident for services that were not provided to the resident, for the period, November 2025 and December 2025. Interviews with five (5) of five (5) staff deny the allegation. According to staff, charges for services stated in the resident’s service plan and admissions agreement are charged to residents in care. Staff interviewed reported that staff who oversee R1’s medical visits conducted at the facility by R1’s Physician’s Registered Nurse (RN) stated only observing the visit and not providing any medical treatment or services to R1 during R1’s medical appointment. Staff stated being instructed by ED Hefner to go inside R1’s apartment during R1’s medical appointment and observe the appointment. Interviews with six (6) of ten (10) residents did not corroborate the allegation. Interviews with R1 revealed that R1 did not request additional services be provided by the facility and that R1 is being billed on a monthly basis by the facility for services not rendered. R1 reported that R1 did not sign any documents related to facility staff overseeing R1’s medical visits conducted by R1’s Primary Physician Care Registered Nurse. Documents reviewed indicated that the facility staff charged R1 for a third-party provided medical services in November 2025 through December 2025, and January 2026 through April 2026. The facility has billed R1 for the sum of $340.00 per month for staff observing R1’s medical appointments. During R1’s medical appointments, R1’s Primary Physicians Care Nurse is providing medical treatment to R1’s wound. Facility staff who are present during the R1’s medical appointment relay the information obtained from R1’s Primary Physicians Care Nurse regarding R1’s prognosis to ED Hefner. Review of R1’s Admissions Agreement and R1’s Medical /Financial Power of Attorney (POA) did not reveal that R1 or R1’s POA authorized additional services for R1 under the signed Admission Agreement. The investigation revealed that R1 is being billed for services rendered to R1 during R1’s medical appointment, which is conducted in R1’s apartment by a Third-Party Medical Professional/Registered Nurse. Staff who are present during R1’s medical appointment do not provide R1 with any services and are present to observe R1’s medical appointment. Based on LPAs interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, (Title 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. Exit interview was conducted with ED Hefner and copy of 9099, 9099C and 9099D were provided with appeals rights.the state’s words, verbatim · CDSS document, Jul 31, 2026 · control 28-AS-20251202102346

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(3)(B)(1) · Plan of correction due date: Aug 5, 2026

87507Admission Agreements (g) Admission agreements shall specify the following: (3) Payment provisions, including thefollowing: (B) Rate for additional items and services, including: (1) A comprehensive description of and the corresponding fee schedule for all additional items and services not included in the fees for basic services shall be listed. This requirement has not been met by evidence: Facility is charging R1 medical appointment visits by R1's Primary Physican Care Registered Nurse in R1's apartment. Staff is charging R1 with services not rendered.the state’s words, verbatim · CDSS document, Jul 31, 2026

Plan of correction: Executive Director (ED) to submit a statement acknowledging that ED has read and will comply with section 87507.

Allegation investigated: Staff do not accord privacy to resident in care.

***This licensing report supersedes the previous licensing report dated 05/19/26 in order to clarify information obtained during the complaint investigation. The investigation findings will remain the same*** On today’s visit, Licensing Program Analyst (LPA) Vaid conducted a follow up visit and met with Executive Director, LeeAnn Hefner. The purpose of the visit was discussed. On 05/19/26, Licensing Program Analyst (LPA) Vaid conducted an initial visit for the above-mentioned allegation. LPA Vaid met with Executive Director LeeAnn Hefner and discussed the reason for the visit. LPA and administrator toured the facility and did not observe any health or safety concerns. LPA Vaid requested, and obtained the relevant documents: Resident #1, face sheet/ID, pre-placement, medical/physicians report, needs and services, admissions agreement. Itemized invoice of assisted living charges for 6 months (November 2025- April 2026). The investigation revealed the following: Substantiated ***This licensing report supersedes the previous licensing report dated 05/19/26 in order to clarify information obtained during the complaint investigation. The investigation findings will remain the same*** Regarding the allegation: Staff do not accord privacy to resident in care. It is alleged that the facility staff are not providing residents with privacy during residents’ visit with their third-party medical professional visits ordered by the resident’s primary physician. Interviews with staff denied the allegation. Staff stated they are required to document observations and report the prognosis of residents’ medical conditions. Staff also stated being instructed by the Executive Director to attend the medical appointments between R1 and their Primary Physician Care Nurse. Interviews with nine (9) of ten (10) residents could not corroborate the allegation. Documents reviewed revealed staff went to R1’s room on multiple dates to observe and report the interaction between R1 and R1’s nurse, who is a licensed medical professional. Per Title 22 Regulations, staff do not have the right to attend residents’ medical appointments between residents and their health care professionals. Staff are to communicate with the medical professional after residents’ medical appointments. According to residents’ interviews, R1 made repeated attempts to refuse facility staff to participate in R1s medical appointment at the facility, however, R1’s request to staff for privacy have been denied by facility staff. The facility staff is not providing residents with privacy when R1’s Primary Physician’ Care Nurse provides medical treatment to R1 at the facility. Per interviews conducted, R1’s Primary Physician’ Care Nurse conduct visits to the facility three (3) times per week, and each time R1’s request to staff for privacy has not been honored by facility staff. Therefore, the investigation revealed that staff are not providing R1 with privacy. Based on LPAs interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies per the California Code of Regulations, Title 22, Division 6 & Chapter 8 were previously issued on 05/19/26, therefore no citation is being issued on today’s visit. Exit interview was conducted and copy of 9099, 9099C were provided to Executive Director LeeAnn Hefner.the state’s words, verbatim · CDSS document, Jul 31, 2026 · control 28-AS-20260512121356

Allegation investigated: Staff do not conduct emergency drills.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation on the allegation listed above. LPA met with Administrator, Leeann Hefner, and explained the purpose of the visit. LPA obtained a copy of the resident and staff rosters, Emergency Disaster Plan, and copies of drills conducted. LPA also conducted interviews with Staff #1 - #8 and Residents #1 - #9. The investigation revealed the following: Allegation – Staff do not conduct emergency drills. It is alleged that for over three years, staff have not conducted a fire, disaster, or emergency drill. LPA obtained a copy of the facility Emergency and Disaster Plan. The plan is being reviewed annually by the administrator. Per staff, drills for different types of emergency are being conducted at least quarterly. A personnel member from the Fire Safety Service company conducts unannounced fire and disaster drills for each shift. Unsubstantiated Staff stated that the drills are mainly for staff and do not include the residents. However, the administrator stated that they are planning to provide residents with the procedures of an emergency and possibly an evacuation drill. LPA received copies of the report and observed that drills of different scenarios are being conducted at least quarterly for each shift. LPA interviewed nine (9) residents. Three (3) out of the nine (9) residents stated that the facility is conducting drills for staff. The rest of the residents are not sure if emergency disaster drills are being conducted. Based on record review and interviews, the facility is conducting emergency/disaster drills at least quarterly for staff. 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. An exit interview was conducted with the Administrator. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 28-AS-20260602150242

Allegation investigated: Staff are charging residents for services not provided.

****This report supersedes the original complaint investigation report dated 05/19/2026. The purpose of the visit is to remove information listed on the initial report. The findings will remain substantiated. *** On 05/19/2026, Licensing Program Analyst (LPA) Vaid conducted a subsequential visit for the above-mentioned allegation. LPA Vaid met with LeeAnn Hefner- Administrator and discussed the reason for the visit. LPA and administrator toured the facility and did not observe any health or safety concerns. On 12/08/25, LPA Vaid conducted an unannounced 10 day initial visit regarding the allegations mentioned above. Met with Administrator Leanne Hefner and discussed the allegations. LPA Vaid requested, and obtained the relevant documents: Resident #1 and #2, face sheet/ID, pre-placement, medical/physicians report, needs and services, admissions agreement. Itemized invoice of memory care charges for 6 months (June 2025- November 2025). Four (4) random residents files (face sheet/ID, pre-placement, physicians report, needs and services were requested and obtained. Admissions agreement (70 pages) for R1 will be emailed to LPA for review. The investigation revealed the following: Continued on 9099C............................. Substantiated Regarding the allegation: Staff do not ensure resident is bathed. It is alleged that the facility staff are not ensuring that R2 is bathed weekly causing a foul odor and rash on R2’s person. Five of five staff deny this; residents are scheduled to bathe as per residents’ service plans. Some residents refuse to bathe as it is their right not to bathe. Staff make repeated attempts with residents in Memory Care, with three different staff faces asking at different times. The staff cannot force the residents to take a bath against their wishes. Staff will ask family to assist and persuade. Nine of ten residents could not corroborate this, interviews revealed residents are assisted with showers/bathes two -three times per week as listed in their needs and services plan. According to resident interviewed, R2 is bathed as their service plan, Resident has not been observed unbathed according to R1 having visited R2 daily. .Regarding the allegation: Staff do not assist resident with getting dressed. It is alleged that the facility staff are not assisting R2 with their clothes and staff are leaving R2 in same clothes for (2-3) two-three days at a time. Five of five staff deny this; residents’ in memory care are assisted with change of clothing regularly. Some residents refuse to change their favorite item of clothing, as it is their right to refuse daily clothing change. Staff make repeated attempts with residents in Memory Care, with three different staff faces asking at different times. The staff cannot force the residents to change clothes against their wishes. Staff will ask family to assist and persuade. Nine of ten residents could not corroborate this, interviews revealed residents in memory care are assisted with clothing changes daily. Some residents acknowledge staff washing favorite clothing item for residents, frequently. Resident interviewed stated having observed R2 with clean clothes, R1 and R2 meet daily. Regarding the allegation: Staff do not meet resident’s incontinence needs. It is alleged that the facility staff are not meeting R2’s incontinent needs and the staff is failing to change soiled briefs for days. Five of five staff deny this, according to staff residents are check for incontinent changes upon starting, during and before the end of each shift, staff stated providing Assisted daily Living needs to residents needing incontinent services three times per shift and as needed for residents requiring constant incontinent care needs. During each shift staff make nighty checks upon incontinent needing residents, staff periodically checks upon residents' needing constant incontinent care due to their medical conditions to avoid residents' developing UTI's and sores on their private areas. Nine of ten residents could not corroborate this allegation. Residents stated they receive incontinent care throughout the day and night and when needed. Residents' also stated, not being left in soiled adult briefs for days, staff tends to residents needs. CONTINUED ON 9099C.................. Regarding the allegation: Resident sustained an injury due to staff neglect and staff did not seek medical attention for resident’s wound in a timely manner. It is alleged that R2 sustained an injury to their person while under facility staff care, and staff failed to communicate the injury and cause of injury to R2’s family. Per allegation staff refused to tend to R2 ‘s wound, stating ‘R2 did not have that level of care’. The lack of care led to the wound developing an infection. Five of five staff deny this allegation, staff stated having communicated R2’s medical condition to R2’s family and physician and were ordered by R2’s primary physician to take R2 to urgent care, staff complied with physician’s orders. R2 was taken to Urgent Care by family and released with prescription medication. Nine of ten residents could not corroborate this allegation, interviews revealed staff are taking proactive measures to ensure residents’ safety and assist residents in avoiding injury. Residents also stated staff have communicated with their physician and family in a timely manner when residents’ injury occurs and residents are transferred to the hospital or urgent care. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s)did or did not occur, therefore the allegations are unsubstantiated. Exit interview was held with Leeann Hefner -Executive Director and copy of this report was provided. ****This report supersedes the original complaint investigation report dated 05/19/2026. The purpose of the visit is to remove information listed on the initial report. The findings will remain substantiated. *** Regarding the allegation: Staff are charging residents for services not provided. It is alleged that the facility is charging R1 for services not provided. Five of five staff deny this allegation, according to staff, charges for services stated in the resident’s service plan and admissions agreement are charged to residents in care. According to staff, the staff overseeing R1’s medical visit by R1’s physicians registered nurse(RN) stated only observing the visit and not providing medical treatment or services to R1 during the medical appointment at the facility inside the residents’ apartment. Staff stated being instructed by LeeAnn Hefner, Executive Director to go inside R1’s apartment during R1’s medical appointment and watch the appointment. Six of ten residents interviewed could not corroborate this. According to documents reviewed, the facility staff charged R1 for third-party provided medical services in November 2025, December 2025, January 2026 through April 2026. The facility has billed R1 for the sum of $340.00 per month for observing and not providing actual medical services to R1, only the primary physicians care nurse is measuring and cleaning the residents wound. The staff is only relayed information from the RN care nurse on R1’s prognosis. Staff are not providing medical services to R1 but are charging R1 for services not rendered. Review of R1’s admissions agreement; R1 and R1’s Medical /Financial Power of Attorney did not authorize additional needs and services for R1 under the signed agreement. R1 stated not signing any document related to facility staff overseeing their medical visits with primary physician care registered nurse. According to interview with R1, did not request in-house care and is not being treated by a qualified facility nurse, and is being charged for services not rendered. Based on LPAs interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, (Title 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. Exit interview was conducted and copy of 9099, 9099C and 9099D were provided with appeals rights.the state’s words, verbatim · CDSS document, May 19, 2026 · control 28-AS-20251202102346

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(3)(B) · Plan of correction due date: Jun 2, 2026

87507Admission Agreements (g) Admission agreements shall specify the following: (3)Payment provisions, including thefollowing: (B)Rate for additional items and services, including: 1. A comprehensive description of and the corresponding fee schedule for all additional items and services not included in the fees for basic services shall be listed. 2. A separate charge for an item or service may be assessed only if that charge is included in and authorized by the admission agreement. 3. A statement acknowledging any additional items and/or services that the resident refused to purchase at the time the admission agreement was signed, which shall be signed and dated by the resident or the resident’s representative, if any, and attached to the admission agreement. 4. If the licensee offers additional items and/or services that were not available at the time the admission agreement was signed, a list of these services and charges shall be provided to the resident or the resident’s representative.5.A statement acknowledging the acceptance or refusal to purchase additional services that were not available at the time the admission agreement was signed, which shall be signed and dated by the resident or the resident’s representative, if any, shall be attached to the admission agreement. 6.The use of third-party services within the facility shall be explained as they are related to the resident’s service plan, including but not limited to, ancillary health, and medical services, how they may be arranged, accessed and monitored, any restrictions on third-party services, and who is financially responsible for the third-party services. This requirement has not been met by evidence: Facility is charging R1 medical appointment visits by R1's primary physican care registered nurse in their apartment. STaff is charging R1 with medical services not rendered.the state’s words, verbatim · CDSS document, May 19, 2026

Plan of correction: Administrator will provide Department with staff training on Privacy and Personal Rights by 06/02/2026.

Allegation investigated: Staff do not accord privacy to resident in care.

Licensing Program Analyst (LPA) Vaid conducted a visit for the above-mentioned allegation. LPA Vaid met with LeeAnn Hefner- Administrator and discussed the reason for the visit. LPA and administrator toured the facility and did not observe any health or safety concerns. LPA Vaid requested, and obtained the relevant documents: Resident #1, face sheet/ID, pre-placement, medical/physicians report, needs and services, admissions agreement. Itemized invoice of assisted living charges for 6 months (November 2025- April 2026). The investigation revealed the following: Regarding the allegation: Staff do not accord privacy to resident in care. It is alleged that the facility staff are not providing resident privacy during residents’ visit with their third-party medical professional visit ordered by Residents primary physician. Staff denied this and stated they are required to document the observation and report the prognosis of residents’ medical condition, staff also stated being instructed by Executive Director to attend the medical appointment between R1 and their primary physician care nurse. Nine of ten residents interviewed could not corroborate with this. CONTINUED ON 9099C........................... Substantiated Documents reviewed revealed staff went to R1’s room on multiple dates to observe and report the interaction between R1 and R1’s nurse, who is a licensed medical professional. Per Title 22 Regulations, residents have the right to have a reasonable amount of personal privacy during residents’ medical appointments between residents and their health care professionals. Staff are to communicate with the medical professional after residents’ medical appointments. According to residents’ interviews, R1 made repeated attempts to refuse facility staff to participate in R1's medical appointment at the facility, however, R1’s request to staff for privacy have been denied by facility staff. The facility staff is not providing residents with privacy when R1’s Primary Physician’ Care Nurse provide medical treatment to R1 at the facility. Per interviews conducted, R1’s Primary Physician’ Care Nurse conduct visits to the facility three (3) times per week, and each time R1’s request to staff for privacy has not been honored by facility staff. Therefore, the investigation revealed that staff are not providing R1 with privacy. Based on LPAs interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies per the California Code of Regulations, Title 22, Division 6 & Chapter 8 were previously issued on 05/19/26, therefore no citation is being issued on today’s visit. Exit interview was conducted and copy of 9099, 9099C were provided to ??.the state’s words, verbatim · CDSS document, May 19, 2026 · control 28-AS-20260512121356

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Jun 2, 2026

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:(1)To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications. This requirement was not met as evidence by: Staff not providing resident with privacy during medical examinations in residents' room by R1's primary physican care nurse.the state’s words, verbatim · CDSS document, May 19, 2026

Plan of correction: Administrator will provide Department with staff training on Residents Admissions agreement by 06/02/2026.

Allegation investigated: Facility staff did not provide required notice of rate increase Facility staff did not meet dietary needs of residents Facility staff did not meet incontinence care needs of resident Facility staff spoke inappropriately to resident

Licensing Program Analyst (LPA) Vaid conducted a subsequential visit for the above-mentioned allegations. LPA Vaid met with LeeAnn Hefner- Administrator and discussed the reason for the visit. LPA and administrator toured the facility and did not observe any health or safety concerns. On 01/30/2026, LPA Vaid collectected resident and staff roster. LPA Vaid conducted interviews with witness and residents #7 to Resident #10. On 09/30/2025, LPA Vaid requested, obtained and reviewed LIC 500 staff roster and client rosters. Resident #1 (R-1)- resident#2 (R2) and resident #3 (R3)- face sheet, LIC 602A-physician report and admissions orders. R1’s last medical care assessment dated- 09/24/25. LPA Vaid interviewed residents #1 to resident #6 and staff. The investigations revealed the following: CONTINUED ON 9099C............................... Unsubstantiated Regarding the allegation: Facility staff did not provide required notice of rate increase. It is alleged that the facility staff is not providing required notice of rate increase to residents. Five of five staff interviewed denied this allegation. According to staff the increase to the rate is delivered to self-responsible residents and residents’ Power of Attorney(POA) by the information on file. R1 and R2’s rate of increase is delivered to R1 and R2’s family. LPA Vaid’s conversation with R1’s POA confirmed delivery of notice of yearly rental increase for R1. W1 stated that R2 is not familiar with payment of the facility dues, W1 stated the family is given 60-day notice of the yearly rate increases for R1. Eight of ten residents could not corroborate this allegation, five of ten stated their family handles their finances and is communicated the rate increases, six of ten residents stated they are given 60 days’ notice for the yearly rate increase. 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. Regarding the allegation: Facility staff did not meet dietary needs of residents. It is alleged that staff are not meeting residents’ dietary needs by not delivering breakfast on time to residents’ room and meal portions are small. Five of five staff deny this allegation; residents are encouraged to eat meals in the dining room to promote socialization amongst the residents. A delivery charge is assessed for meals deliveries to residents’ rooms; delivery charge is not assessed for residents with serious medical conditions who cannot attend dining room meals. Seven of ten residents could not corroborate this allegation, residents stated they have the correct meals served according to their health and dietary plans, meal sizes are reasonable. Three of ten residents stated they have requested and received extra portions of meals. 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. CONTINUED ON 9099C............................. Regarding the allegation: Facility staff did not meet incontinence care needs of resident. It is alleged that the staff is not meeting residents’ incontinent needs, staff left R1 in soiled diaper for 24-hours. Five of five staff deny this allegation, staff stated residents with incontinent needs are periodically checked throughout each shift by caregivers to ensure residents are dry and comfortable in their briefs. Seven of ten residents could not corroborate this allegation, residents interviewed don’t have incontinent needs. Two of ten residents stated staff checks on them periodically throughout the day. Their incontinent needs are met daily, two of ten residents stated being checked on very 2-hours due of over active health issue. 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. Regarding the allegation: Facility staff spoke inappropriately to resident. It is alleged that staff spoke inappropriately to resident, and resident observed staff speaking rudely and making a resident cry. Five of five staff interviewed deny this allegation, staff stated they are respectful of the residents in memory care and assisted living and treat all residents with dignity and respect. Staff stated they do not speak about residents’ issues in public, rather meet in private and discuss issues with the residents and their families. R3 denied having a confrontation with S1 over past issue. Seven of ten residents could not corroborate this allegation; residents stated the staff does not speak to them in a rude or inappropriate manner and residents stated never having witnessed staff making residents feel sad. Residents stated staff is cheerful and helpful. 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 was held and copy of investigation report was provided to Administrator, LeeAnn Hefner.the state’s words, verbatim · CDSS document, Mar 12, 2026 · control 28-AS-20250924155016

Allegation investigated: Staff do not respond to resident's calls for assistance in a timely manner Staff did not provide resident's responsible party with required notice of fee increase Staff do not ensure that resident is treated with dignity and respect Staff do not ensure resident's room is clean and sanitary

Licensing Program Analyst (LPA) Sanjay Vaid made a subsequent complaint investigation visit. LPA met with LeeAnn Hefner, Executive Director, and discussed the purpose of the visit to deliver finding to the above mentioned allegations. Toured the physical plant and did not observe any health and safety concerns. On 08/01/2025, LPA Vaid conducted an unannounced 10-day complaint visit and met with LeeAnn Hefner- Executive Director and the purpose of the visit was discussed. LPA Vaid requested and obtained the following documents: LIC 500-staff roster and resident roster. Residents' face sheet, pre-appraisal/physicians report, residents' self-acknowledgement information form, admissions agreement, service and needs plan, resident shower schedules, private caregivers’ attendant registration and information form, facility letter to caregivers’ requiring mandatory forms, correspondence with residents' family. CONTINUED ON 9099C................ Unsubstantiated Regarding the allegation: Staff do not respond to resident's calls for assistance in a timely manner. It is alleged that the staff is not responding to residents’ call for assistance with the residents’ needs in a timely manner. Six of six staff interviewed deny this. According to the staff interviewed, the staff responds to the residents’ call for assistance within twenty minutes and staff will notify and alert another staff members when one staff person is delayed assisting other residents that reside on the floor. Nine of ten residents interviewed could not corroborate the allegation. Six of ten residents stated the staff responds to their call for assistance within ten to fifteen minutes. Based on interviews and observations, 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. Regarding the allegation: Staff did not provide resident's responsible party with required notice of fee increase. It is alleged that staff are not providing resident’s responsible party with notice of fee increase. Six of six staff interviewed deny this. According to the staff the yearly increases are in accordance with the residents’ admissions agreement and care service descriptions. The notifications are mailed from the corporate office to self responsible residents and the residents Power of Attorney via United States Postal Service and or preferred communications. Nine of ten residents interviewed could not corroborate this allegation. Six of ten residents stated they are aware of and are notified by the facility for increase in rent and services required for resident’s needs. According to records reviewed, R1 and R1’s financial Power of Attorney agreed to all the terms of the admissions agreement, including cost increase of needs and services, signed and dated on 07/08/2024. Based on interviews and records reviewed, 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. Regarding the allegation: Staff do not ensure that resident is treated with dignity and respect. It is alleged that the staff are not treating residents with dignity and respect. Six of six staff interviewed deny this. Staff stated they treat each resident with respect and dignity. Staff are providing care and comfort to all residents. Staff stated they provide a safety and harmonious environment for all residents in memory care and assisted living. Seven of ten residents interviewed stated they feel safe and secure residing at the facility. Five of ten residents stated they are treated with kindness and dignity and stated they have never been ridiculed and made to feel embarrassed. Based on interviews and observations, 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. CONTINUED ON 9099C....... Regarding the allegation: Staff do not ensure resident's room is clean and sanitary. It is alleged that the staff are not ensuring residents’ room is clean and sanitary and trash is not collected frequently. Six of six staff interviewed deny this. Staff stated they clean each room according to the assigned schedules. Staff collect trash from the residents’ room, bathroom and trash placed by residents’ door. Staff performing housekeeping duties, cleaning and sanitizing the residents’ room and bathroom, and removing all the trash. Staff performing janitorial duties keep corridors clean and clear of trash. Based on interviews and observations, 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 copy of report provided to Executive Director LeeAnn Hefner.the state’s words, verbatim · CDSS document, Jan 26, 2026 · control 28-AS-20250728103245

Allegation investigated: Licensee did not abide by the terms and conditions of resident's admission agreement.

Licensing Program Analyst (LPA) Alberto Lopez made a subsequent complaint investigation visit. LPA met with Melodie Misaikone, Move-in Coordinator and Alicia Aragon, Health Service Director and discussed the purpose of the visit. On 09/26/2025 LPA interviewed one (1) resident (R#1) and one (1) staff member (S#1) via phone. On 07/15/2025 Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced 10-day complaint visit at the facility and met with Executive Director LeeAnn Hefner to discuss the purpose for today’s visit. Investigation consisted of: Resident roster, staff roster, a copy of the admissions agreement, interview with the administrator, and interviewed 2 residents. Investigation revealed: Due to insufficient information available at this time, the above allegation(s) need(s) further investigation. (continued on 9099C) Unsubstantiated (continued from 9099) 09/26/2025 During this visit LPA obtained copy of staff and resident roster, and R1 admission agreement. On 09/27/2025 LPA obtained copy of R1 v=care plan. The investigation revealed regarding allegation: Licensee did not abide by the terms and conditions of resident's admission agreement. It is alleged that the facility is charging R1 an extra fee to walk R1 dog even though R1 is able and still walks R1 dog. LPA interviewed four (4) staff S#1 – S#4 and all four (4) staff denied the allegation. LPA interviewed ten (10) residents, and all ten (10) residents could not corroborate the allegation. Administrator, S1 stated that when R1 returns from grocery shopping, R1 struggles to carry grocery bags and hold resident’s pet dog’s leash and that R1 lets go of the leash and then the dog roams around and bothers other residents who have complaint to Administrator about it. The administrator told R1 that she may have to charge R1 extra to have staff assist R1 to make sure R1 does not let R1’s dog loose in the facility. Administrator stated that R1 never paid for this service and is not currently being charged for this service. LPA interviewed R1 and R1 stated that this is old news and that the Administrator is not charging R1 and R1 never paid a cent for this service. R1 stated R1 does not need this service and refused it. R1 stated resident is happy with this arrangement. There is insufficient evidence to support this allegation. Based on records reviewed, interviews conducted, and observations indicate that, although the allegation may have happened 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 was conducted and copy of this report was given to Alicia Aragon, Health Service Directorthe state’s words, verbatim · CDSS document, Sep 27, 2025 · control 28-AS-20250711162059

Allegation investigated: Staff isolates resident. Staff has inappropriate interaction with resident.

Licensing Program Analyst (LPA) Vaid conducted an unannounced 10-day complaint visit and met with LeeAnn Hefner- Executive Director and the purpose of the visit was discussed. As of todays visit: LPA has toured the physical plant. LPA interviewed staff #1-6 (S1-S6) and residents #1-10(R1-R10). Requested and obtained LIC 500-staff roster and resident roster. Residents' face sheet, pre-appraisal/physicians report, admissions agreement, service and needs plan, resident shower schedules copies of documents from residents’ file related to the allegations. The investigation revealed the following: Unsubstantiated Regarding the allegation: Staff isolates resident. It is alleged that the staff is isolating residents in their rooms and not allowing them to come out of their room due to mal body odor from the resident. (6) of (6) staff interviewed denied the allegation. (10) of (10) residents interviewed could not corroborate the allegation. Interviews with staff acknowledge a few residents with strong body odors. Staff assist residents with their Assisted daily living needs. Residents are encouraged by staff to shower on their scheduled days. Some residents refuse to shower as scheduled. Staff will attempt three times during their shift to convince the resident to shower and then change personnel and attempted to convince three times again. Records reviewed show R1's scheduled for shower twice weekly and refusing to shower. Staff communicates residents’ behaviors to next shift. Residents are never left alone; staff interact with residents when making their rounds. Family and physician are informed of residents’ behaviors. LPA observed the resident in the common area watching TV interacting with other residents. Based upon record review and interviews conducted the findings indicate that, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: Staff has inappropriate interaction with resident. It is alleged that the staff make shaming remarks about residents’ foul body odor during the mealtime and resident is forced to eat in their room. (6) of (6) staff interview denied this allegation. (10) of (10) residents interviewed could not corroborate this allegation. Interviews with staff acknowledged that a few residents have strong body odor. Staff encourages residents to keep up with their hygiene and are not shaming any of the residents for their body odor. Staff understands the behaviors that residents have and assists the residents with their needs and services. The residents are allowed to wander the facility freely. Staff acknowledge that some residents will make remarks towards residents with a foul odor. Staff interviewed stated they assist all residents with comfort and safety and treat residents with respect and dignity. Based upon record review and interviews conducted the findings indicate that, although the allegation may have happened or are 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 was conducted and copy of this report was given to Lee Ann Hefner- Executive Director.the state’s words, verbatim · CDSS document, Sep 11, 2025 · control 28-AS-20250904125106

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) S Vaid conducted the required annual inspection. LPA arrived unannounced and met with Claudella Farrow-receptionist who notified the administrator LeeAnn Hefner arrived shortly after and assisted with the assisted with the tour. The facility is licensed to serve 142 non-ambulatory residents ages 60 and over, of which eight (8) may be bedridden, approval for twelve (12) hospice. There is an approved delayed egress for memory care. The building is a three-story building which was consisted of the front lobby, the memory care unit, common areas, resident rooms and private bathrooms, public bathrooms, dining rooms, central restaurant style kitchen, offices, housekeeping closets, activity rooms, bar area, beauty salon, theater room, laundry and linen storage and supply rooms, and medication rooms. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and cleaning/disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Dementia Plan and training, and facility maintains the required liability insurance. Con't 809C...... Physical Plant & Environment Safety: LPA toured facility, ten (10) residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested daily throughout the facility resident private restrooms and measured within the required range of 105-120 degrees. There is a shaded patio and garden area for residents. Staffing: There is always sufficient staffing in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training: Staff have criminal record clearance, current First-Aid training along with training in postural supports, assisted living, memory care, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 5 staff files with no issues observed. Administrator LeeAnn Hefner certificate expires on 3/29/25, renewal was sent and is awaiting. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 10 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman posted in the front lobby and common areas. Planned Activities: Facility provides scheduled activities with a monthly calendar. There is an outdoor activity area available for the residents. LPA observed residents participating in planned activity. Con't 809C................... Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Dining staff uses approved menus and follow residents special diets. Walk-in fridge and freezers temperatures are measured and recorded daily. Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a Medication Room and are in their original containers. LPA reviewed medications for six (6) assisted living residents and four (4) memory care residents. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Fire and disaster drills are conducted unannounced monthly by third party company during different shifts. Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies. Facility admits residents with dementia and staff have all required training documented within personnel files. There are currently one (1) in bedridden resident in hospice at the facility. LPA observed rooms that have oxygen with the required signs posted. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to LeeAnn Hefner.the state’s words, verbatim · CDSS document, Aug 19, 2025

Allegation investigated: Staff are not keeping resident rooms at a comfortable temperature

Licensing Program Analyst (LPA) S Vaid made an unannounced complaint visit to the facility and was met by concierge Claudelle Farrow and requested census. Executive Director Leeann Hefner arrived shortly after. Purpose of visit was discussed. The investigation consists of the following: LPA Vaid requested, obtained and reviewed staff roster resident/client roster, recent HVAC company work-order, receipts of purchased portable fans and A/C units. Emails between HVAC project manager and Administrator Hefner, regarding A/C work timeline. Staff interviews# 1-5(S1-S5), resident interviews# 1-9(R1-R9) and conducted tour of the facility. LPA Vaid viewed residents’ rooms and measured the air temperature with the thermometer issued by the Department. Regarding the allegation: Staff are not keeping resident rooms at a comfortable temperature. It is alleged that the facility staff are not keeping the residents’ rooms within a comfortable temperature level. CONTINUED ON 9099C................ Unsubstantiated Five (5) out of five (5) staff could not corroborate this allegation, according to the staff the facility did have Air Conditioner issues with a A/C units that affected thirteen (13) occupied rooms and two (2) unoccupied rooms and common areas. On 04/29/25 the facility A/C units had issues and HVAC company was called out to repair. On 05/02/25 compressor parts for the malfunctioned A/C units were ordered. On 05/30/25 the parts were delivered, and A/C unit was partially repaired, the circuit board to the A/C unit was damaged and needed replacement and was ordered. On 06/06/25 the compressor was replaced but A/C systems still had issues. Portable fans and portable A/C units were and provided to the residents affected. Additional portable A/C units and fans were purchased on 06/19/25 and 6/23/25. 06/27/25, HVAC company ordered new parts, new parts arrived 7/5/25 and the A/C system was now under repair. The HVAC company and Maintenance Director are checking cooling in the affected residents’ rooms. Unusual incident report was faxed to the licensing department on 07/02/25 by the Executive Director regarding the A/C repairs. Nine (9) out of nine (9) residents interviewed were not able to corroborate the allegation, according to the residents the A/C was out for couple of weeks but only some areas and rooms were affected. Review of resident medical records by LPA Vaid did not corroborate this allegation. According to one resident the A/C breakdown does not cause their health conditions to become worsen in hot weather. Residents’ claim the A/C breaking down is hassle, but the facility staff were able to accommodate them by providing fans and portable A/C units. Residents interviewed confirm the facility staff provided portable fans and A/C units placed in the residents' rooms. The air temperature was measured in nine (9) residents’ rooms affected by the A/C malfunction. During tour of facility, the temperature in the residents’ rooms were measured by LPA using State issued thermometer and the range is within of 78-85 deg F, which is within the regulations. Residents' R1-R9 stated that they are comfortable with the air temperature, they are able to control the temperature in their room via thermostat. Based on records reviewed, interviews conducted, and observations made the findings indicate that, although the allegation may have happened or are 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 was conducted and copy of this report was given to Leeann Hefner, Executive Director.the state’s words, verbatim · CDSS document, Jul 8, 2025 · control 28-AS-20250703155158

Allegation investigated: Resident sustained a fracture due to staff neglect. Staff did not prevent physical altercation between residents. Staff did not meet resident's incontinence needs. Staff did not provide resident with clean linen.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 04/26/2025 to deliver findings regarding the above allegations. LPA Villalobos conducted a Health & Safety visit on 02/06/2025 and a needs further investigation was documented. During today’s visit, LPA Ramirez was greeted by Alicia Aragon and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster, Interviews conducted by Community Care Licensing-Investigations Branch, Staff interviews#1-5 (S1-S5) conducted by LPA Ramirez, Attempted interview of resident#1 (R1) by LPA Ramirez, Attempted interview of R1’s responsible party by LPA Ramirez, Copies of R1’s: Physician’s Medical Assessment (LIC 602A), Admission Agreement, Staff charting notes for R1, and physical plant tour. See 9099-C Unsubstantiated The investigation revealed the following: regarding the allegation(s)- Resident sustained a fracture due to staff neglect. It is alleged that R1 sustained a fracture due to staff neglect on 12/16/2024. Interviews conducted by Community Care Licensing-Investigations Branch did not corroborate this allegation. Review of R1’s resident records by Community Care Licensing-Investigations Branch did not corroborate this allegation. 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. Staff did not prevent physical altercation between residents. It is alleged that facility staff did not prevent physical altercation between R1 and R2 on 12/16/2024. Interviews conducted by Community Care Licensing-Investigations Branch did not corroborate this allegation. Review of R1’s resident records by Community Care Licensing-Investigations Branch did not corroborate this allegation. 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. Staff did not meet resident's incontinence needs. It is alleged that staff did not meet R1’s incontinence needs. Five (5) out of the five (5) staff interviewed by LPA Ramirez did not corroborate this allegation. LPA Ramirez attempted to interview R1 but, R1 was unavailable for an interview. LPA Ramirez attempted to contact R1’s responsible party but, R1’s responsible party was not available for an interview. Review of R1’s resident record by LPA Ramirez did not corroborate this allegation. During tour of facility, LPA Ramirez observed residents to be well groomed and not malodorous. 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. Staff did not provide resident with clean linen. It is alleged that facility staff did not provide R1 with clean linen. Five (5) out of the five (5) staff interviewed by LPA Ramirez did not corroborate this allegation. LPA Ramirez attempted to interview R1 but, R1 was unavailable for an interview. LPA Ramirez attempted to contact R1’s responsible party but, R1’s responsible party was not available for an interview. Review of R1’s resident record by LPA Ramirez did not corroborate this allegation. During tour of facility, LPA Ramirez observed resident rooms to be free from malodorous and observed sufficient supply of extra clean linen in laundry room. 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. No violations were cited for this complaint investigation. Exit interview was conducted. A copy of this report was provided via email.the state’s words, verbatim · CDSS document, Apr 26, 2025 · control 28-AS-20250206102807

Allegation investigated: Staff did not dispense residents’ medication as prescribed.

Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent unannounced complaint investigation visit for the allegation(s) listed above. LPA met with staff Melodie Misaikone and the purpose of the visit was discussed. Administrator Leann Hefner was notified via phonecall. Adminstrator arrived shortly after. As of todays visit: LPA has toured the physical plant, interviewed Staff #1-7 (S1-S7), interviewed residents #1-#6 (R1-R6), interviewed R1's home health agency (W1),collected copies of the staff and resident rosters, collected copies of documents from R1's file related to the allegations. The investigation revealed the following: In regards to the allegation "Staff did not dispense residents’ medication as prescribed." it is alleged that R1 went two days without receiving the proper medications. (3) of (7) Staff confirmed the allegation. (6) of (6) Residents interviewed could not corroborate the allegation... Continued on LIC 9099-C Substantiated In regards to the allegation "Staff did not provide adequate supervision, resulting in a resident sustaining multiple falls" it is alleged that R1 has had multiple falls in the facility in the last year due to lack of supervision. (7) of (7) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews with staff only showed knowledge of one fall where R1 slipped from their wheelchair. Staff were present and able to assess R1. 911 was also called but no injuries were noted. File review shows an SIR dated 6/2/24 on the incident provided to licensing. There were no other recordings of falls R1 may have had in the facility. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. 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. In regards to the allegation "Staff neglect resulted in resident sustaining an unexplained injury" it is alleged that due to staff neglect of supervision R1 received a unknown burn on their hand. (7) of (7) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews stated that blisters were observed on R1's hand on 10/8/24. Staff interviewed denied any knowledge of what caused the blisters. Interviews added that the blisters were initially observed by R1's relative while they were in private. Once staff became aware, they assessed R1 and called paramedics. There was no knowledge of the blister prior to the family visit. File review shows there is an incident report on file for this day. Staff stated there are no chemicals in the open near R1's bed and R1 receives total assistance with mobility around the facility. This means staff are present and near R1 when moving anywhere in the facility. Interview with R1's home health agency stated the blisters classify as a burn but the cause remains unknown. The blister was in between the finger and more resembled friction burn rather than a chemical burn. LPA observed R1's room to be free of any items that pose a danger. LPA observed staff supervision to be sufficient. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. 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. Continued on LIC 9099-C In regards to the allegation "Staff did not assist resident with eating" it is alleged that staff did not assist R1 with eating their meals after their left hand was bandaged. (7) of (7) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews stated that R1 had a bandaged left hand but eats with their right hand. Staff interviewed stated that R1's care plan requires cut up food and encouragement but not to be fed directly. Staff stated they however do make sure R1 finishes their meals and will assist if R1 needs it. LPA observed R1 eating in the facility on their own during the initial visit. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. 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. In regards to the allegation "Staff did not provide resident’s records to authorized representative in a timely manner" it is alleged that R1's family requested resident records but the facility would not provide them. (7) of (7) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interview with staff stated that R1's responsible party requested, in writing, for a list of documents from R1's file on 10/29/24. Staff stated the documents have been gathered as of 10/31/24 and R1's responsible party was notified they can be picked up. File review confirms the date of the request and the date the documents were provided. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. 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. In regards to the allegation "Staff did not communicate with resident's authorized representative regarding care in a timely manner" it is alleged that the facility has not communicated any changes in R1's care plan since R1 moved in. (7) of (7) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff interviewed stated R1 moved in on 11/24/23 and there have been no changes since the finalized care plan completed on 1/26/24. This plan was communicated with R1's responsible party. File review showed last service plan on file for R1 was created on 1/26/24. Staff stated the plan is still current and there have been no changes. LPA was not informed of what changed were done that needed to be communicated. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. 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 was provided. Interviews showed that there were medication errors on 9/1/24 and 9/2/24 for R1 regarding their Depakote medication. On 9/4/24, Staff observed the medication still in the bubble pack for those two days meaning that R1 did not receive it. Review of R1's file shows that R1 requires assistance with medication from staff. File review also showed an incident report was created to report the missing medications to licensing and in service training was scheduled with staff. This shows that the facility failed to dispense R1's medication as prescribed. Based on LPA's observations, record reviews and interviews conducted the preponderance of evidence standard has continue therefore the above allegations are found SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8 on LIC 9099D. Exit interview conducted. Appeal rights discussed. A copy of this report and the appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 13, 2025 · control 28-AS-20241028085133

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 14, 2025

87465(a) A plan for incidental medical and dental care shall be developed...The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: R1 was not assisted with their Depakote medication between 9/1-9/2/24 which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2025

Plan of correction: POC cleared at the time of the visit. Facility has reported incident as required and conducted in-service training for staff that assist residents with medication.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tao conducted an unannounced Case Management- Incident visit in response to resident#1 (R1) Incident Report, dated 10/05/24. The facility has a capacity of 142 residents, licensed to serve elderly residents age 60 and above, approved for 142 non-ambulatory residents and has dementia program in place. LPA explained the purpose of today's visit to LeeAnn Hefner, administrator who assisted with this visit. During today's visit, LPA conducted physical plant, conducted interviews including Administrator, staff#2-staff#3, resident#1 (R1) and family member (FM), reviewed R1's file and staff file. LPA attempted but unable to reach staff#4 (S4) and the agency caregiver (S5) for interview. The incident report stated an agency caregiver (S5) reported to administrator that staff#4 (S4) was rough with resident#1 (R1) while providing care. The agency caregiver reported S4 did not use the Hoyer Lift to transfer resident, grabbed resident by resident’ neck and did not provide proper pericare to resident. LPA interviewed Administrator/staff revealed that the facility investigated the incident, put the alleged staff (S4) on an immediate suspension on 10/04/24, and reported the incident to Licensing/ ombudsman / responsible party/ police on 10/05/24. The staff interviews revealed it was a single incident and resident#1 (R1) was not injured nor physically abused. Staff S4 was a new hired and had completed training on providing care to dementia residents. S4 was voluntarily terminated on 10/07/24 after the incident. After the incident, the administrator hosted a brief meeting with caregivers regarding the proper procedures on providing cares to residents with dementia and using Hoyer Lift. Per interview of R1, resident seemed unable to recall the incident and did not observe injury on resident’s neck or back. R1 was on a daily monitor by staff for a week. FM interview revealed R1 was doing fine and did not complain any pain after the incident. Police case#24-22261. (-continued on LIC 809C-) LPA obtained copies of the following documents: · Staff roster · Resident roster · R1’s Identification/Emergency Contact Information (facesheet) · Unusual Incident Report · Physician Report · Staff #4 staff files/document · In-service training LPA did not observe nor identify signs of neglect, abuse or other immediate health and safety threats. No deficiencies were observed and cited during this visit. Exit interview was held with administrator and this report LIC 809 was provided to administrator.the state’s words, verbatim · CDSS document, Oct 29, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit to the facility. LPA met Lee Ann Hefner, administrator and the purpose of today's inspection was explained. The facility is licensed to serve age range 60 and over, approved for (142) non-ambulatory, including eight (8) may be bedridden. Delayed egress was approved. The facility had approved hospice waiver for twelve (12) for residents residing in bedrooms# 101,102,103,104,121,122,123, and 124. LPA conducted staff/resident interviews, used CARE inspection tool, conducted physical plant, reviewed food supply/medications and records/ staff/residents’ records. Facility fees were current. Administrator certificate was current until 3/29/25. The building was a three-story building which was consisted of a front lobby, memory care unit, common areas, resident rooms and private bathrooms, public bathrooms, dining rooms, central restaurant style kitchen, offices, housekeeping closets, activity rooms, bar area, beauty salon, theater room, laundry and linen storage and supply rooms, and medication rooms. The memory care unit was located on the first floor. A delayed egress door system and alarm system were operational. The signal system were tested and staff arrived within 8 mins. Physical plant was conducted in room 114, 117, 135, 230, 224, and 327. Residents’ bedrooms and bathrooms were in compliance. Hot water temperature was measured in a range of 114.2 to 115.1 degrees Fahrenheit which was within Title 22 Regulation guidelines. Landline telephone systems were operational and available for resident use. Smoke/carbon monoxide detectors were monitored by a fire alarm company and last service was on 5/10/24. Fire extinguishes were fully charged. (-continued on LIC 809 C-) Sufficient supply of perishable and non-perishable foods was observed. A comfortable temperature of 75 degrees Fahrenheit maintained throughout the entire facility. No bodies of water observed. Staff and resident files will be kept in the director's office on the second floor. Elevators for residents' use were operational. Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview was held. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 30, 2024

Allegation investigated: Illegal eviction

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation on the allegation listed above. LPA arrived unannounced and met with Executive Director, Lee Ann Hefner. The purpose of the visit was explained. LPA obtained a copy of the staff roster, resident roster, and documents pertaining to Resident #1. LPA interviewed the Executive Director, Wellness Director, and family member. For the allegation of an illegal eviction, LPA conducted interviews and reviewed documents to determine findings. Per the Executive Director, an eviction letter was never issued to Resident #1 (R-1). R-1 moved into the facility on 6/1/24. On 6/3/24, the facility contacted 911 because R-1 was displaying chest pain due to the aggressive behavior. Unsubstantiated R-1 was sent out to the hospital and when ready for discharge, R-1’s daughter moved resident back to own home with the one-on-one caregiver. Per the Executive Director and Wellness Director, they denied telling the hospital staff they were not accepting the resident back as alleged. LPA reviewed the facility documents which showed that the Wellness Director conducted a reassessment of R-1 on 6/5/24 at R-1’s private home. The Wellness Director also stated that R-1’s daughter was informed of the change in level of care and understood the cost will increase. Staff was told that R-1 was coming back to the facility after the weekend. However, the family came on the weekend to move out all of the belongings without informing any staff. LPA interviewed R-1’s family member, who heard from a hospital personnel that the facility was not accepting resident back but did not confirm with the Executive Director if information was true. Based on the information gathered, there is insufficient evidence to support this allegation of the illegal eviction. 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. An exit interview was conducted with the Executive Director. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 9, 2024 · control 28-AS-20240701133013