Parkview Memory Care at Paradise Village

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management Visit to correct/amend a report. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Katrina Jimenez, Executive Director. During today's visit, LPA formally amended a prior facility evaluation report from 08/04/2026 and discussed the changes made with the Licensee. Licensee agreed to remove any copies of the prior report they have, substituting/replacing with the amended report. No deficiencies were observed or cited during today’s visit. An exit interview was conducted with Jimenez, to whom a copy of the amended report, this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Aug 18, 2026

Allegation investigated: Staff hit resident Staff yelled at resident

Licensing Program Analyst (LPA)Tiffany Holmes conducted an unannounced visit to close out an investigation on the above-mentioned allegations. LPA was granted entry by Front Lobbyist and then met with Leah Adolfo, Health Services Director and explained the purpose of the visit. LPA previously conducted interviews with residents, staff, and outside sources, made observations, and obtained and reviewed pertinent records. LPA Correia conducted the initial visit on August 08, 2023 and May 24, 2024 and conducted a tour of the facility . It was alleged that the staff hit resident and the staff yelled at resident. Interviews revealed that on 7/23/23 Staff 1 (S1) was trying to change Resident 1 (R1’s) brief’s. According to interviews, R1 was resisting being changed and S1 called for assistance. S2 and S3 came to assist. Staff interviews revealed both staff observed S1 smack R1 to get them to comply. Interviews revealed that R1 was agitated and went to punch staff, that’s when S1 smacked R1 and yelled at them, “You don’t hit me” and then smacked them. Interviews revealed after S1 smacked R1 they were able to change R1’s briefs. Interviews revealed that the staff that was with S1 told management about how S1 acted. During the course of the investigation it was revealed that the facility conducted their own internal investigation; however, they never documented the interviews conducted during the investigation. Interviews revealed shortly after S1 was allowed to return to work they resigned. Interviews also revealed that since the complaint was opened that R1 had passed away. The Department has investigated the above-mentioned allegations and based on interviews, LPA observations, and records review, it was determined that the complaint allegations are substantiated. The allegations are valid, and preponderance of the evidence has proven that the alleged violations occurred. Deficiencies are listed on the 9099d page An exit interview was conducted with Leah Adolfo, Health Services Director and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit. Substantiatedthe state’s words, verbatim · CDSS document, Aug 4, 2026 · control 08-AS-20230731093707

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Aug 21, 2026

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: (1) To be accorded dignity in their personal relationships with staff…” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not treat 1 of 53 residents (R1) with dignity. This posed an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: Licensee agreed to complete an inservice regarding personal rights for all staff by the POC due date of 8/21/2026. Licensee will provide LPA Holmes a copy of the sign in sheet and training materials by email by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Aug 21, 2026

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:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not speak respectfully to 1 of 53 residents (R1). This posed an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: Licensee agreed to complete an inservice regarding physical and verbal abuse for all staff by the POC due date of 8/21/2026. Licensee will provide LPA Holmes a copy of the sign in sheet and training materials by email by POC due date.

Allegation investigated: Staff left resident's bed soiled Staff are not meeting resident's diapering needs Staff left resident in soiled diapers Staff are not taking residents to the restroom Staff inappropriately had residents on video calls

Licensing Program Analyst (LPA) Jose De La Cruz conducted an unannounced visit regarding the above allegation. LPA was greeted by Health Services Director Leah Adolfo, to whom he identified himself and explained the purpose of the visit. On January 14, 2026, the Reporting Party (RP) alleged that the facility was not meeting Resident 1’s (R1) toileting and diapering needs. RP alleged that R1 was left in soiled diapers and soiled bed, and that staff were not taking the resident to the bathroom when needed. RP stated that staff were double-diapering residents and making personal video calls in which residents were visible on screen. On January 20, 2026, LPA conducted a phone interview with RP, who reiterated the allegations. According to RP, multiple witnesses, including staff, residents, and R1’s spouse, had observed these incidents. RP reported that if the LPA visited the facility after 12:00 PM, it was highly likely the LPA would witness similar situations. [CONTINUED ON LIC9099-C] Unsubstantiated [CONTINUED FROM LIC9099] On January 20, 2026, LPA visited the facility from 12:20 PM to 4:25 PM to commence the investigation. LPA requested records, toured the facility, and interviewed staff, residents, and residents’ family members. The staff interviewed (S1, S3, S4, S5, and S6) could not confirm the incidents described by RP. LPA later interviewed S2, who also did not corroborate the allegations. LPA interviewed Resident 4 (R4) and an outside source (OS1), who typically visited the facility Monday through Friday from 1:00 PM to 3:00 PM, and occasionally on Saturdays to see resident 4 (R4). OS1 stated they were satisfied with both the facility and the staff, and had never observed any incidents related to the allegations. OS1 also stated that staff primarily communicate through walkie talkies rather than cell phones, and use those devices to coordinate resident care. OS1 reported never seeing a resident wait longer than five minutes for assistance. LPA toured the facility and entered eleven randomly selected rooms on both floors. No unkept rooms or soiled residents were observed. LPA also checked for double diapering or staff on their phones, and did not find evidence supporting the allegation. LPA attempted to contact R1’s spouse (OS2) by phone several times between January 20, 22 and 26 on, but received no answer. OS2 later responded by text message, stating they did not make the complaint and that RP had made the allegations. OS2 asked LPA to speak directly with RP, and did not respond to any further calls or messages. LPA contacted RP on March 13th, 2026, to report that witnesses did not corroborate the allegations and that no similar incidents were observed during the visit. RP claimed to have photographs and sent them to LPA on two separate occasions. LPA informed RP that the photographs lacked sufficient context, as it was not possible to determine how long the residents waited or whether the photos were taken at the facility. LPA agreed to conduct an additional visit to determine whether these incidents were occurring. On July 7, 2026, LPA conducted an additional visit after 2:30 PM and met with R1 while touring the facility. R1 appeared clean, comfortable, and responsive, sitting in the common area reading a magazine. LPA observed residents and staff in the common area and did not witness any incidents similar to the allegations. LPA further observed staff working in coordinated teams, communicating resident needs, and assisting residents to their rooms for clothing changes as necessary. Based on interviews, record review, and LPA observations, the preponderance of evidence standard was not met. Therefore, the allegation is unsubstantiated. No deficiencies were cited in accordance with Title 22 of the California Code of Regulations. Report and Appeal Rights were discussed with and provided to the Health Services Director Leah Adolfo. The signature below confirms receipt.the state’s words, verbatim · CDSS document, Jul 22, 2026 · control 08-AS-20260114114322

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Required Annual Inspection. LPA identified himself and discussed the purpose of the visit with Executive Director Katrina Jimenez. The facility is licensed for a maximum capacity of 70 non-ambulatory residents, 6 of which may be bedridden. The facility has a waiver for 15 hospice residents. LPA, accompanied by Executive Director toured the interior and exterior of the facility, and inspected several random resident rooms. The entire facility serves as a memory care unit. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. Hot water temperature was measured in the facility at 111 degrees F. The ambient temperature inside the facility was measured at 76 degrees F. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas. Their are no bodies of water on the premises. Per Executive Director, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-C] LPA reviewed multiple staff and resident records/files. LPA file review did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Executive Director Katrina Jimenez whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, May 19, 2026

Allegation investigated: Neglect/Lack of Supervision resulted in serious injury.

On 02/21/2026, LPA Janet Ngallo conducted a subsequesnt visit to deliver findings regarding the above-mentioned allegation. LPA spoke with Resident Care Coordinator Patricia Pestano and explained the purpose of the visit. Regarding the allegation of Neglect/Lack of Supervision resulted in serious injury, resident (R1) had several falls in the facility causing R1 to have hip fractures. During the investigation, staff members were interviewed, and records were reviewed. Facility staff reported they initiated more supervision when able and frequent status checks every hour because R1 was considered to be a fall risk. S1 & S2 completed numerous assessments to determine an accurate service and care plan for R1 and to increase assistance with services and care. (Cont. on LIC 9099-C) Substantiated (Cont. from LIC 9099) R1 was sent to the hospital several times due to the falls, and during the falls had sustained a left hip fracture 6/11/2024 and a right hip fracture 08/2024 while residing in assisted living. S2 said they completed multiple assessments and recommended additional supervision for R1. Staff reported that additional status checks were implemented and R1s medications were changed by physician to assist R1 with sleep and anxiety. Facility staff notified family during any change of condition or when an incident occurred. The incident was documented, and timely medical care was provided. R1 had nine falls while residing in assisted living and three falls within one month of residing in memory care. On 09/05/24, the facility had a care conference with the family recommending a personal caregiver and a higher level of care for R1. R1 had six additional falls after the care conference. At the time of the complaint visit, Resident Care Coordinator Patricia Pestano was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49. Based on interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D. An Immediate Civil Penalty of $500.00 was also assessed/charged (refer to the LIC421-IM page). An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Resident Care Coordinator Patricia Pestano, whose signature below confirms receipt of these rights. (Cont. from LIC 9099) For the allegation of Insufficient Staff, RP alleged that facility appeared to be understaffed. Facility schedule shows that on certain days the ratio for care staff and residents will be 1:7 or 1:8. Night shift has three staff scheduled which starts at 10:00 pm. For the allegation of Staff lack training, RP stated that some of the night shift caregivers were not qualified to meet the needs of residents. According to records review, all staff go through the required initial and annual training all through their tenure in the facility. Based on interviews and records review, the department has determined that although the allegations 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 and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to ______, whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Feb 21, 2026 · control 08-AS-20250207145638

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Feb 22, 2026

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...of the facility require such additional staff for the provision of adequate services. This was not met as evidenced by: Based on interviews and records review, Licensee failed to provide increased supervision to R1 and cause R1 to have multiple falls which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 21, 2026

Plan of correction: Staff will provide proof of scheduled training with management staff within 24 hours to LPA via email. Training will be completed and submitted to LPA with sign-in sheet and training topic clearly noted via email by 02/25/2026.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Katrina Jimenez and Health Services Director Leah Adolfo. Today's visit was in response to an LIC624 Incident Report, which Licensee self-submitted to the CCLD San Diego Regional Office (received on 02/02/2026). Per this LIC624, Resident #1 (R1) had an unwitnessed fall on 01/31/2026, and facility staff subsequently sent R1 to local hospital emergency room (ER) on 02/01/2026. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, LPA performed a brief facility tour / welfare check on R1, collected and reviewed relevant care and medical records, and interviewed R1 and multiple pertinent facility staff. Due to their Alzheimer’s Disease diagnosis, R1 was not a reliable historian. However, records and staff interviews taken together showed: On 01/31/2026, R1 fell three (3) times inside their bedroom within one day, at around 11:50 AM, 1:00 PM, and 6:21 PM, respectively. The 11:50 AM fall did not involve any suspected injury. The 1:00 PM fall involved a bump on head, for which 911 paramedics responded, but for which R1 and their responsible person also declined transport to the hospital. The 6:21 PM fall involved pronounced pain to R1’s right shoulder area, which was immediately apparent to responding facility staff. Rather than call 911 again for R1, staff assisted R1 to bed and alerted R1’s hospice agency. Facility staff provided R1 as-needed morphine for pain, and the hospice agency dispatched a nurse a few hours later to perform a follow up visit on R1. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] However, by the morning of 02/01/2026, R1 remained in pain, and their right shoulder area was now significantly discolored, so staff arranged for R1 to be transported to the hospital ER; R1 departed the facility around 11:03 AM. Per hospital ER records, R1 was diagnosed with a new “closed displaced comminuted fracture of shaft of right humerus.” (A comminuted fracture is a type of injury where the bone breaks in multiple places. A displaced fracture means the fragments have moved out of normal anatomical alignment, creating a gap or misalignment.) CCR 87465(g) requires Licensees to “immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health.” Regarding residents receiving hospice care, CCR 87469(c)(3) specifies, “For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).” CCLD concluded that the injury to R1’s right shoulder/arm was serious and required staff to call 9-1-1. This injury also was not related to the expected course of R1’s underlying terminal illness/diagnosis. To date: The available evidence did not clearly show that Licensee’s delay in activating 911 worsened R1's injury. The available evidence also showed that Licensee had performed Care Plan updates/reappraisals on R1 in the past, as required. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Executive Director Katrina Jimenez and Health Services Director Leah Adolfo, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Feb 4, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87469(c)(3) · Plan of correction due date: Feb 4, 2026

87469 Advanced Directives and Requests Regarding Resuscitative Measures: “(c)(3) Specifically for a terminally ill resident that is receiving hospice services…For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).” This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 49 residents (R1), who was receiving hospice care services and experiencing an emergency not directly related to the expected course of their terminal illness, Licensee’s staff did not immediately telephone emergency response (9-1-1). This posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Feb 4, 2026

Plan of correction: On 02/02/2026, prior to CCLD’s case management visit, Licensee had already conducted an in-service retraining with its staff, educating them to call 911 when the resident’s medical emergency is not directly related to the expected course of the resident’s terminal illness. Licensee reminded its staff that while a resident and their responsible person may refuse transport to the hospital, such refusals should be made directly to first responders, after said personnel have already met with and inspected the resident. The Plan of Correction is Satisfied.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Interim Executive Director Nicole Long. The facility is licensed for a maximum capacity of 70 non-ambulatory residents, 6 of which may be bedridden. The facility has a waiver for 15 hospice residents. During today’s visit, the facility had a census of 42 non-ambulatory residents. The Administrator for the facility is Katrina Jimenez and their certificate was valid and current. During today’s visit, LPA toured the facility and inspected a random sampling of resident bedrooms and bathrooms, common bathrooms for general use, facility kitchen, common areas, and outside space. LPA observed small water fountains located within the facility's enclosed courtyards. LPA observed delayed egress on facility exit doors in accordance with the facility's fire clearance approval. LPA did not observe any aspects of secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 118.0, 118.4, and 118.6 degrees Fahrenheit in a random sampling of resident bathrooms. The facility’s internal temperature was measured at 70, 72, and 74 degrees Fahrenheit across the facility. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Nicole Long, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 40 degrees Fahrenheit, and the facility freezer was kept at -2 degrees Fahrenheit. Continued on LIC809-C page… LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, initial medical assessment, updated annual reappraisal, documents regarding safeguarding personal property and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA provided Interim Executive Director with consultation and guidance regarding the regulation changes that became effective 1/1/2025. LPA also provided guidance regarding reporting requirements and updating facility information. No deficiencies were cited on today’s date. An exit interview was conducted with Interim Executive Director Nicole Long, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Jul 14, 2025

Allegation investigated: Questionable Death

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced complaint visit to deliver investigative findings. LPA met with Interim Executive Director, Nicole Long, and shared findings. The Department investigated the above-listed complaint allegation. The investigation consisted of observations, interviews with facility staff and outside sources, and a detailed review of relevant records, such as investigative law enforcement reports, residents’ medical records, and service care plans. On January 4, 2024, Community Care Licensing (CCL) received a complaint alleging the questionable death of a resident (R1), on December 21, 2023. It was specifically alleged that on December 14, 2023, staff did not provide care and supervision to meet residents' needs which resulted in R1 succumbing to injuries sustained from a possible assault by another resident (R2) [staff was provided LIC 811 Confidential Name List to identify the residents]. (Continue at LIC9099C) Unsubstantiated (Continue from LIC9099) Based on records review and interviews with relevant witnesses it was indicated that on December 14, 2023, there was an incident involving R1 and R2. At 6:15 a.m. during safety checks, staff observed R1 lying on the floor in R2’s room. Per staff interviews, there were no witnesses of the incident. Staff obtained immediate medical attention by emergency medical responder personnel for R1 who was transferred to the hospital via ambulance. A detailed review of R1 and R2’s medical records indicated that both residents were diagnosed with dementia and were under memory service care plans. In addition, both residents had a history of “sundowning” (confusion, anxiety, agitation, or aggression that can occur in the late afternoon or early evening) behavior. R1 was non-ambulatory and needed assistance to transfer in and out of bed. R1’s primary diagnosis was Parkinson’s disease; R1 did not have inappropriate or aggressive behavior but was confused/disoriented. R2 was ambulatory and able to independently transfer in and out of bed. R2’s medical records under “mental condition” the box for “Confused/Disoriented” was marked as “yes”. For inappropriate and aggressive behavior, the box was marked as “no”. In addition, both residents were in neighboring rooms, sharing a “Jack and Jill” adjoining bathroom. A review of the admission agreements and the pre-admission assessments for R1 and R2 indicated that they both were new residents (R1 was admitted on 11/18/2023 and R2 was admitted on 11/29/2023), to the facility with no history of aggressive or violent behavior. All the staff that worked on December 14, 2023, were interviewed on the date of the incident. The responsible parties of both residents were interviewed as well as an attempted interview with R2 was conducted on December 14, 2023. Due to R2’s documented dementia medical condition, they were not able to provide relevant details of the incident. Based on interviews with the assigned investigator with the County of San Diego Medical Examiner’s Office, the incident was ruled as “accidental” by the Medical Examiner’s Office. A review of relevant medical reports indicated that R1’s physician stated that R1’s cause of death was determined as blunt force trauma to their head. It was determined there were no witnesses to what, if anything, had occurred directly between residents R1 and R2, such as a physical altercation. According to interviews conducted with facility staff safety check protocols were adhered to during the shift when the event occurred. Safety check logs were obtained and reviewed which confirmed the required documentation of the safety checks. (Continue at LIC9099C) (Continue from LIC9099C) The Department has investigated the above-mentioned allegation and based on interviews with staff, residents, outside sources, and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Interim Executive Director, Nicole Long, to whom a copy of this report, LIC811 Confidential Name List, and the Licensee Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 11, 2025 · control 08-AS-20240104102521

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted a case management visit. LPA was greeted by, Interim Executive Director, Nicole Long to whom she identified herself and discussed the purpose of the visit. During today's visit, Interim Executive Director, Nicole Long signed a complaint report delivered during a compliant visit conducted on 4-11-2025. An exit interview was conducted with Interim Executive Director, Nicole Long, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Apr 11, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Health Services Director Alyssa Ukaj. Administrator Geovanni Aguilar later arrived to meet with LPA. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office. According to the LIC624: on 6/17/24, Resident #1 (R1) was involved in an incident where staff restrained R1 in order to change a soiled brief after R1 went several hours refusing to be changed. [See LIC 811 Confidential Names List for a description of R1.] . No injuries reported. Facility reported incident to law enforcement, notified R1's responsible party, staff who were involved in the incident were written up and terminated, facility conducted in service training for all staff on personal rights, restraints and abuse/mandated reporting. During today’s visit, LPA performed a facility tour / welfare check, collected records, observed R1 and interviewed staff. One (1) deficiency was cited per California Health and Safety Code (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the Administrator. An exit interview was conducted with Aguilar, to whom a copy of this report, the LIC809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Aug 29, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Sep 29, 2024

(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 requirement is not met, evidenced by Based on records and interviews, Licensee's employee physically restrained resident (R1), preventing them from leaving the facility. This posed a potential safety risk to 1 of 48 clients in care.the state’s words, verbatim · CDSS document, Aug 29, 2024

Plan of correction: Licensee will conduct an in-service training on personal rights, and abuse training for staff on and provide sign in sheets to the Department by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Health Services Director Alyssa Ukaj. Administrator Geovanni Aguilar later arrived to meet with LPA. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office. According to the LIC624: on 7/10/24, Resident #1 (R1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of R1.] R1 was located on facility grounds. During today’s visit, LPA performed a facility tour / welfare check, collected records, and interviewed staff and client. According to R1’s latest LIC602 Physician’s Report their doctor determined that R1 is unable to safely leave the facility unassisted. Interviews and records showed that Licensee had a written Absentee Notification Plan as part of R1’s record of care, and that staff followed this plan. No deficiencies were cited for this incident. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Aguilar, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Aug 29, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Administrator Geovanni Aguilar. According to the facility’s license, the facility is licensed for seventy (70) non-ambulatory residents, six (6) of whom may be bedridden. Facilities current census is fifty-two (52). LPA, accompanied by Administrator, toured the interior and exterior of the facility, and inspected client bedroom’s. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Extra linens and hygiene supplies were present. Hot water temperature was in compliance. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water on premises. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher and first aid kit present. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients and reviewed multiple staff/client files. The files which LPA reviewed contained all required documents. No deficiencies were cited during today's annual inspection. An exit interview was conducted with Administrator to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jul 30, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Geovanni Aguilar. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 11/28/2023). According to the LIC624: on 11/27/2023, Resident #1 (R1) briefly eloped (left without staff supervision) from the facility building. [See LIC 811 Confidential Names List for a description of R1.] R1 was quickly located and escorted back to the facility unharmed. During today’s visit, LPA performed a brief facility tour and welfare check, verifying that R1 was unharmed. LPA reviewed and collected copies of pertinent care records. LPA also interview R1 and relevant staff. According to R1’s latest LIC602 Physician’s Report (dated 11/01/2023): R1 was diagnosed with Dementia, and their doctor determined that they were not able to safely leave the facility unassisted. Interviews and care records showed: R1 had moved into the facility about a week before the incident. On 11/27/2023 around 10:45 AM, a staff person saw R1 in the facility’s parking lot and redirected R1 back inside, unharmed. Ten to twenty minutes prior, R1 was seen inside the facility by multiple staff. Camera footage showed R1 exited from a corner of the facility where there were no doors. Staff observed within this immediate area was a vacant resident room, where there was a broken window stop (designed to prevent the window from being fully opened) and a dislodged window screen. The parking lot where R1 was located was immediately adjacent to this window. Although R1 could not recall details of the elopement incident, circumstantial evidence showed that R1 forcibly exited the facility via this window. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] LPA observed: Licensee had since repaired the above referenced window stop and window screen. Staff alert and delayed-egress devices on exit doors (where residents diagnosed with Dementia reside) were operational. Licensee possessed a written Absentee Notification Plan as part of R1’s record of care. Licensee had since updated R1’s Plan of Care to increase routine observation for them. Training records shows: On 11/28/2023, Licensee educated direct care staff on how to respond to residents’ “Wandering Behavior” and “Exit Seeking Behavior.” During today’s visit, LPA reviewed data on R1’s biography and likes and dislikes, which Licensee had obtained as part of its pre-admission appraisal. LPA provided Licensee with Technical Assistance (TA) on how to make this information more accessible and actionable to the direct care staff. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Aguilar, to whom a copy of this report, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Nov 29, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Geovanni Aguilar and Resident Services Director Tatiana Soltero. Today's visit was in response to two (2) LIC624 Incident Reports and two (2) SOC341 Reports of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office on 09/08/2023. The reports described alleged personal rights violations committed by Staff #1 (S1) against Resident #1 (R1) and Resident #2 (R2) on 09/05/2023, and which had since come to the licensee’s attention. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. During today’s visit, LPA performed a facility tour and welfare check on R1 and R2, finding that both were safe. LPA also collected copies of pertinent care records and interviewed multiple relevant staff. According to R1’s latest LIC602 Physician’s Report (dated 05/09/2023): R1 was diagnosed with “senile degeneration of the brain / dementia.” According to R2’s latest LIC602 Physician’s Report (dated 04/11/2023): R2 was diagnosed with “expressive language disorder” and “other unspecified disorders of the brain.” Manager and staff interviews unanimously showed that both R1 and R2 were cognitively-impaired as part of their baseline condition. LPA likewise observed that neither R1 nor R2 had the memory skills or verbal skills to be reliable interviewees. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Staff interviews, corroborated by time and date-stamped records, showed: During the evening of 09/05/2023, R1 did not want to receive personal care from S1. S1 used their own hands to physically restrain R1’s hands. S1 then used their fingers to pinch R1’s neck and spoke disrespectfully about R1 in front of them, towards Staff #2 (S2), who witnessed the above. Also during the evening of 09/05/2023, R2 did not want to receive bathroom assistance from S1. R2 was in their wheelchair and grabbed onto the doorframe of their bathroom in protest. Rather than stop, S1 continued to pull on R2’s wheelchair handles until R2 slid out of the wheelchair and onto the floor. This latter act was witnessed by S2 and Staff #3. Staff #4 did not witness the moment R2 slid out, but responded post-incident and corroborated that they personally helped R2 up off the floor. R1 and R2 did not suffer observable injuries from the incident. Records and staff interviews unanimously showed: Licensee became are of the above incidents on 09/06/2023, and immediately placed S1 on administrative leave pending further investigation. The same day S1 was placed on leave, they resigned from employment. Licensee’s own internal investigation concluded that S1 had committed the above alleged actions. A preponderance of evidence exists to show that during the incidents in question, licensee’s staff (S1) did not ensure that residents in care (R1 and R2) were free from humiliation and physical abuse. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Aguilar, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Oct 25, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1 · Plan of correction due date: Oct 26, 2023

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: (3) To be free from…humiliation…abuse…” This requirement was not met, as evidenced by: Based on records and interviews, licensee’s staff (S1) did not ensure that 2 of 59 residents (R1 and R2) were free from humiliation and abuse, which posed an immediate health, safety, personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Per staff and manager interviews: S1’s employment ended on 09/06/2023, resolving the immediate risk. Licensee agreed to retrain its direct care team at large on: a) Resident’s Personal Rights, b) Mandated Reporting Requirements, and c) How to correctly manage behaviors and refusal of care for residents diagnosed with dementia. Licensee agreed to submit a copy of the handouts used and the training sign-in sheet to LPA, by 11/24/2023.