People's Care Charmian

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a case management visit and was greeted by facility caregiver. Administrator (Admin) Guadalupe Garcia arrived later. On 7/29/26 CCL received an Incident Report indicating a medication error for resident (R1). Report indicates that on 7/26/26 Admin was contacted by facility staff requesting verification before administering a PRN medication for R1 due to not having a bowel movement within 12 hours. Admin reviewed the bowel movement tracker and verified the date and time of the last documented PRN dose. Per Incident Report, there was no bowel movement recorded for R1 that day. So, staff administered the PRN medication. However, approximately one (1) hour after the medication was administered, staff (S1) called facility to advise that they remembered that R1 did actually have a bowel movement, but they did not record it on the bowel movement tracker. Admin immediately contacted the on-call nurse to advise of the medication administration in error. On-call nurse advised that no adverse reactions would likely be caused by the PRN medication being administered. Later in the day on 7/26/26 R1 was seen at the Emergency Room due to blood being observed in their private buttock area. Admin advised hospital staff of PRN medication administration error. Per Incident report, Emergency Room physician confirmed that the PRN medication administration error had not caused any harm or adverse reactions. R1 was subsequently evaluated, treated, and discharged back to the facility. Staff monitored R1 for any changes. R1 had a follow-up appointment the subsequent week. Continued on 809C... Continued from 809... LPA reviewed discharge papers and telephone follow up doctor's notes for R1. Discharge papers indicate follow up appointment. LPA reviewed follow-up appointment summary from 7/31/26. No adverse reactions observed. Per Admin, S1 has been terminated due to the pattern and consistency of medication related errors and failure to follow established procedures. All staff received additional training on proper documentation and medication administration. Additionally, Admin advised LPA that additional coaching and corrective action will be provided as needed to reinforce expectations for timely documentation and communication practices. Additionally, LPA discussed two (2) recent Incident Reports submitted in August for R1 falling. LPA discussed with Admin reason for increased falls. LPA reviewed doctor's office visit notes which indicates R1's diagnosis as drug induced Parkinson's who presents with worsening tremor and functional decline. A civil penalty in the amount of $250 is being assessed today for repeat violations within a 12 month period (see LICF21) Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Sep 16, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 17, 2026

Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: Based on facility's submitted incident report indicating medication error for R1 which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: Facility to submit copies of termination documentation of S1 by plan of correction due date. Additonally, facility conducted medication training following the medication error. Training records to be submitted to CCL by no later than plan of correction of due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a case management visit and was greeted by facility caregiver. LPA met with Administrator (Admin) Guadalupe Garcia. On 6/5/26 CCL received an Incident Report indicating a medication error for resident (R1). Report indicates that on 5/30/26, at approximately 9:00pm Admin was notified that staff (S1) had signed for Nystatin powder that was not administered to R1. Upon facility investigation, it was determined that R1 missed one 5:00pm dose. Facility terminated S1 on 6/8/26 for falsifying documentation. On 6/16/26 CCL received an Incident Report indicating a medication error for resident (R2). Report indicates that on 6/15/26 Administrator was notified that staff (S2) had administered a dose of Claritin D that is prescribed to be given only once every 24 hours. S2 administered the second dose without verifying the time the previous dose had been administered. R2 was subsequently seen by their physician. Resident was monitored for adverse reactions. No adverse reactions observed. Facility has conducted medication training with staff with an emphasis on reviewing MARs, medication instructions, dosage requirements, and administration procedures. Additionally, Administrator will conduct periodic audits of medication records. S2 will be receiving final written today and a Counseling and Corrective Action (CCA). Admin showed LPA paperwork for corrective action. On 6/17/26 CCL received an Incident Report indicating a medication error for resident (R3). Report indicates that on 6/16/26 facility Administrator was notified by staff that staff (S3) administered two (2) medications prescribed for hypertension. However, R3's blood pressure was reading was outside the administration parameters specified on doctor's orders. Additionally, S3 did not report their error to the Administrator. Upon learning of the error, Administrator immediately contacted nurse consultant for guidance and requested a Continued on 809C... Continued from 809... doctor visit for R3. Resident was monitored for adverse reactions. No adverse reactions observed. R3 was seen by a doctor 7/13/26. Report indicates S3 will receive disciplinary action up to and including termination. Admin advised LPA that S3 is the staff member that verified the falsification records for R1. Due to these incidents, S3 was terminated on 7/6/26. LPA discussed with Administrator the seriousness of these medication errors and actions taken and/or in need of being taken to ensure residents do not experience medication errors. So many errors in such a short period of time indicate a need for a better structure for medication management. LPA and Administrator discussed the times and places at which medications are administered. Perhaps changing the structure of how and when medications are administered will help to eliminate any distractions or confusion for the staff doing the administering. Admin advised LPA that she has already analyzed the medication administration procedure and has begun implementing changes with staff. A civil penalty in the amount of $250 is being assessed today for repeat violations within a 12 month period (see LICF21) Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Jul 16, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 17, 2026

Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: Based on facility's submitted incident reports indicating medication errors for R1, R2, and R3 which pose an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 16, 2026

Plan of correction: Facility to send copies of disciplinary corrective actions. Facility to submit copies of disciplinary corrective action by plan of correction due date. Additonally, facility to submit written plan idenifying medication administration procedure and medication management program outlining how facility will ensure all residents receive prescribed and PRN medications according to doctor's orders. Copies of disiplinary action forms and written plan due to CCL by plan of correction due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a case management visit and was greeted by facility designee. Administrator (Admin) Guadalupe Garcia was present. Admin certificate 7030880740 expires 5/4/27. On 5/4/26 CCL received an Incident Report indicating a medication error for resident (R1). Report indicates that on 5/1/26, at approximately 8:45pm R1 was administered one (1) tab of 1mg Benztropine instead of the prescribed two (2) tabs of 1mg Benztropine on 4/29/26 and 4/30/26 (deficiency cited, see 809D). R1 was monitored for adverse reaction and was observed to have no adverse reactions. All required partied were notified. Per Redwood Family Care Network District Manager (DM), Arneatha Simon, the error was observed when the medication bubble pack was reviewed on 5/1/26. Per DM, staff were trained on medication management on 5/4/26. LPA reviewed training records. Additionally, staff responsible for error are to receive disciplinary action, actions are pending corporate review and will be administered within 7 days. On 5/14/26 CCL received an Incident Report indicating a medication error for resident (R2). On 5/12/26, during a medication audit, it was discovered that R2 did not have a doctor's order on file for their Omeprazole 20mg, given twice daily (deficiency cited, see 809D). Per DM, it was determined that R2 arrived at the facility with the medication and a MAR was created for administration. There was record of a request for a formal order from the treating physician with no response. Rene Litzenberg, RN, requested the doctor order on 5/12/26, and DM sent a second request via the KP.org communication portal on 5/13/26. There was no response by the treating physician at the end of the business day. At approximately 7:00pm on 5/13/26 R2 was taken to Kaiser to determine if the medication needed to continue to be administered. R2 returned to the facility at approximately 10:30pm with a doctor order to administer Omeprazole 20mg twice daily. Continued on 809C... Continued from 809... Per DM, facility staff were not responsible for the error. Per DM, the facility Administrator is responsible for logging in medications and ensuring that doctors' orders on file. However, due to administrative actions, the facility was in the interim of hiring an administrator. As of 5/11/26 facility has hired an Administrator, Guadalupe Garcia. LPA discussed with Admin her understanding of medication requirements. LPA and Admin also discussed and went over regulations for medication, food, physician reports, emergency supplies, personnel documentation, and nutrition requirements. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, May 19, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 20, 2026

Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: Based on facility's submitted incident report indicating medication error for R1, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 19, 2026

Plan of correction: Facility conducted staff training on 5/4/26 for medication management. Per DM, staff responsible for error will receive disciplinary corrective action, actions are pending corporate review and will be administered within 7 days. Facility to send copies of disciplinary corrective action by no later than 5/26/26. Facility to submit plan to submit copies of disciplinary corrective action by plan of correction due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(e) · Plan of correction due date: May 20, 2026

87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.the state’s words, verbatim · CDSS document, May 19, 2026

Plan of correction: Facility Administrator has sole responsible for ensuring doctor's orders are on file. Facility was in the process of finding an Administrator. As of 5/11/26 an Administrator was hired. LPA discussed medication requirement with Admin. Deficiency cleared.

Type of visit: Office

Licensing Program Manager (LPM) Victoria Bertozzi, and acting Regional Manger Kimberly Mota, and Licensing Program Analyst (LPA) Christi Coppo met with licensee Redwood Family Care Network Representatives Arneatha Simon, District Manager (DM), and Kayava Lenoir Regional Director (RD) at the Santa Rosa CCL Regional Office. This Office Meeting is being conducted to discuss the Decision and Order signed on April 21, 2026. The Order states that the Administrator Certificate for Patrick Seawright’s will be revoked effective May 1, 2026. LPM and LPA discussed with DM and RD the need for an administrator to be present at facility and that the removal of Patrick Seawright will need to promptly be addressed as resident care must remain in compliance with Title 22 and Health and Safety Code (HSC). The facility does not currently have a replacement Administrator but the licensee is actively seeking a replacement. Licensee is now recruiting and conducting interviews for a replacement including seeking Administrator Certification for a current staff member. The current House Manger is enrolled in the Administrator Certification course and completion date is expected to be May 14, 2026. Licensee has also reached out to a temporary staffing agency. Licensee representative agrees to continue to update the regional office on their search and will ensure compliance with regulation 87405(a) which states: (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a Continued on 809C.... Continued from 809... sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. Exit interview conducted with licensee representatives and a copy of this report given.the state’s words, verbatim · CDSS document, Apr 30, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo conducted an office meeting with People’s Care licensee representative Kayava Lenoir, regarding the removal of Administrator Patrick Seawright as Administrator of the facility. Also during office meeting, LPA discussed most recent incident report submitted to CCL on 4/13/26. On 4/13/26 CCL received an Incident Report for facility indicating a medication error for resident (R1). Reports states that on 4/9/26 R1 was not given their evening dose of Lisinopril 5mg (deficiency cited, see 809D). Report indicates that R1’s primary care physician was notified. Report indicates that R1 was monitored by staff for adverse reactions and behaviors; none were observed. Report indicates that staff responsible for error will be disciplined accordingly and training will occur. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with licensee representative. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.the state’s words, verbatim · CDSS document, Apr 30, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 30, 2026

Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed This requirement not met by licensee as evidenced by: Based on facility's submitted incident report reporting medication error, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: Facility to submit plan to conduct medication management training for all staff administering medication by plan of correction due date. Training to be completed for a duration of at least 1 hour and completed no later than 5/14/26. Staff disciplinary records to be submitted to CCL by 5/7/26.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Patrick Seawright, Administrator. Administrator certificate number 7011807740 expires 5/25/26. Facility currently has two (2) residents in care none of which are currently on hospice. At approximately 10:30am LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled with opened dates present. Cleaning products and laundry soaps are locked and inaccessible to residents in care. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sinks measured at 118.3 degrees F in the kitchen and 117.4 in the bathroom used by residents, both of which are within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 12/16/24. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted on 09/1/25. Facility has a backup generator for use during a power outage. At approximately 10:45pm LPA and Admin reviewed cash resources. No deficiencies cited. Continued on 809C... Continued from 809... At approximately 11:00pm LPA conducted a review of two (2) out of two (2) resident files and five (5) of six (6) staff records. Files complete. At approximately 12:00pm LPA and Licensee conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet.. LPA and Admin discussed Infection Control Plan. LPA and Admin discussed Emergency Disaster Plan. No changes to either plan. No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Oct 28, 2025

Type of visit: Case Management - Other

On 3/12/25 Licensing Program Analyst (LPA) Christi Coppo met with Administrator Patrick Seawright for a Case Management Regional Office meeting to follow up on substantiated complaint allegations; complaint number 21-AS-20240214082730. On May 16, 2024, the Department concluded an investigation which alleged that a staff did not seek medical attention for a resident (R1) in a timely manner, and due to staff neglect, R1 sustained a blister on their leg. The licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87411(a) Personnel Requirements due to staff severe neglect as resident sustained a blister on their leg when staff put a heating pad on their leg. Additional citation was issued under California Code of Regulations (CCR) Title 22, § 87466 Observation of the Resident, Staff did not seek medical attention for resident in a timely manner when change of condition was observed. At the time of the complaint visit on May 16, 2024, an immediate civil penalty of $500.00 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code §15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation." This is evidenced by the facility staff putting a heating Continued on 809C... Continued from 809... pad on R1, causing a blister, later to be identified as a 2nd degree burn, failing to seek timely medical care once blister was observed and then continuing to not seek timely medical care until after it had burst. Today, 3/12/25 the Department is issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on May 16, 2024, the amount of the civil penalty issued today will be $9,500. A copy of the LIC 421D was given to Administrator Patrick Seawright and originals were signed. Exit interview conducted. A copy of the report issued. Appeal rights provided. Administrator Patrick Seawright's signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Mar 12, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a case management visit and was greeted by facility administrator, Patrick Seawright. Administrator could not be present for entire LPA visit. LPA conducted exit interview with and gave appeal rights and copy of report to caregiver. On 9/17/24 CCL received an incident report from the facility regarding a medication error. Reports states that on 9/17/24, due to staff error, resident (R1) did not receive their dose of Amuity Ellipta 200mcg. R1 did not receive the medication due it being empty, a refill was not ordered in time. Reports indicates that R1 was monitored throughout the day for any adverse effects. No signs or symptoms of adverse effects observed. Per Admin, facility put in place ordering procedures to mitigate errors in refilling of medications. As of today, 3/12/25 CCL has not received any further incident reports for medication errors from the facility. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with caregiver. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. On 1/13/25 CCL received a SOC341 from the facility self-reporting a case of abuse toward a resident by a staff member. Facility Admin, Patrick Seawright submitted the SOC341 report. Report indicates that on 1/6/25 staff (S1) observed staff (S2) push resident’s (R2) wheelchair on to R2’s knees in an attempt to get them to get into their wheelchair. On 1/6/25 S1 reported this incident to a new hire orientation trainer. The new hire orientation trainer sent an email to People’s Care QA auditor. On 1/8/25 S1 then reported the incident to facility Admin. Facility Admin then immediately went over to R2 to check the status of their legs Continued on 809C... Continued from 809... and observed no marks or bruising. On 1/12/25 facility Admin contacted S2 and placed them on Administrative leave. As of today, 3/12/25 S2 is back on active duty at the facility. Starting on 1/8/25 People’s Care Quality Assurance auditor (QA) began an investigation into the incident. Investigation lasted approximately one week and took another 2 weeks to report their findings. Admin advised LPA they did not receive any written statements from the staff. LPA asked Admin for the findings of the investigation. Admin advised they can produce the findings for CCL by 3/31/25 as they must ask the investigator for a copy of the findings. Per Admin, due to inconsistent details of the incident being reported to the QA investigator over the course of the investigation, S2 has returned work. Facility Admin reports R2 has not had any adverse behaviors observed resulting from the incident. No deficiencies cited for this SOC341 incident. Exit interview conducted with caregiver and a copy of this report was given.the state’s words, verbatim · CDSS document, Mar 12, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 13, 2025

Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: Based on facility's submitted incident report reporting medication error, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 12, 2025

Plan of correction: Facility put in place ordering procedures to mitigate errors in refilling of medications. Facility to submit plan to CCL by plan of correction due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Patrick Seawright arrived later. At approximately 9:30am LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 110.3 degrees F in the kitchen and 114.8 degrees F in the back bathroom which are within the allowable range of 105 to 120 degrees F. LPA and Admin discussed adding either non-skid mat or strips to showers as required per regulation. Fire extinguishers were last inspected 11/27/2023, but are showing as charged. LPA and Admin discussed ensuring fire extinguishers are serviced annually. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted 11/30/24. Facility has a backup generator for use during a power outage. At approximately 10:00am LPA conducted review of 5 staff records. All required documentation present. At approximately 10:30am LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies Continued on 809C... Continued from 809... At approximately 11:00am LPA conducted a review of 3 resident records. All required documentation present. Patrick Seawright Administrator Certificate 7011807740 expires 5/25/26. LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance Exit interview conducted with caregiver, Administrator had to leave. Caregiver given permission to sign. A copy of this report was given. No deficiencies cited.the state’s words, verbatim · CDSS document, Dec 5, 2024

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

Allegation investigated: Resident's needs are not being met Personal Rights Facility staff do not have required First Aid and/or CPR certification Facility does not provide activites Facility is not following doctor's orders

At approximately 3:00pm, Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings regarding the above allegations and met with Patrick Seawright, Administrator. Complaint alleges resident's needs are not being met. RP states that resident is being fed according to another resident’s care plan. During investigation LPA reviewed facility’s meal plan for resident and physician’s report. Per the resident’s physician report, no special diet is required. Per the resident’s Individual Service Plan (ISP) they are to have a mechanical soft diet. Facility has a detailed Daily Routine Cheat Sheet for the resident which outlines very specific foods and mealtime instructions for staff as well as also identifying their care needs that should be attended to each day. LPA finds that daily routine cheat sheet is comprehensive. Facility provided meal meus that are comprehensive and include a wide variety of foods and snacks. Continued on 9099C... Unsubstantiated continued from 9099... During LPA investigative visit, as well as previous visits, LPA observed staff preparing resident’s meal according to resident’s specific dietary needs as outlined in their ISP. Additionally, complaint alleges resident’s legs not being elevated per their care plan because their hospital bed was broken. Investigation revealed that bed’s foot raising feature was broken for approximately one week. However, the primary way by which resident’s legs were elevated is by use of wedges and pillows. The bed being broken did not prohibit resident’s legs from being elevated as the foot raising feature was used as a supplemental aid to help raise and elevate the legs; it was not the main source of elevation. So, 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. Complaint alleges Personal Rights. RP states that resident postural support chair (recliner) was not implemented timely by facility which resulted in resident not being able to be in common areas of facility. During investigation, LPA reviewed doctor’s orders and there is no mention of a postural support chair being needed. Resident’s wound care doctor noted that the legs being elevated would be good but did not specify the method by which the legs should be elevated. Investigation revealed that request was made by resident’s POA for a postural support chair in beginning in March. Per LPA interviews, POA wanted the recliner placed in a certain area of the home, in order to accommodate the request, facility needed to stabilize the base of the recliner and made the request to do so with a handyman. On April 18, 2024 facility added the use of a recliner to resident’s care plan. On April 30, 2024 LPA received a request inquiry from facility in regards to the use of a recliner for resident as a postural support chair. LPA and facility discussed maintaining compliance with regulations as pertains to implementing the recliner as part of resident’s care plan. On May 7, 2024 LPA gave the okay for use of the recliner. Per LPA investigation facility addressed recliner request and made the required notifications and requests to licensing within a span of 60 days. The absence of the recliner chair cannot confirm that resident that resident was isolated due to lack of chair. So, 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(2)... Continued from 9099C(2)... Complaint alleges Facility staff do not have required First Aid and/or CPR certification. During investigation LPA observed one staff member to not have 1st Aid/CPR training. However, this staff was just recently hired and only ever was scheduled to work with another staff member present at all times. All other staff have current 1st Aid/CPR. Per Health and Safety Code 1569.618(c)(3), the facility shall employ at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. So, 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. Complaint alleges Facility does not provide activities. During investigation LPA observed residents participating in activities. During LPA annual inspection in 2023 and all subsequent visits to the facility in 2024, each time LPA was present at the facility, LPA has observed residents participating in activities. Facility has a readily visible large assortment of games, puzzles, and a wide and varying amount of art supplies available, all of which are stored in front living room. So, 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. Complaint alleges Facility is not following doctor's orders. During investigation LPA reviewed doctor’s care notes for resident. Per LPA review of resident’s Individual Service Plan (ISP), current list of doctor’s orders, care notes, and doctor visit summary, facility is following doctor’s orders. Resident’s Daily Routine Cheat Sheet is in line with doctor’s orders, physician’s report, and ISP. Doctor notes wound care is adequate as wound is almost completely healed. Facility In-Service training records show staff training on resident’s specialized equipment and for resident’s wound care. Complainant indicates resident losing weight due to possible neglect. Investigative review of doctor visit summary indicates despite adequate caloric intake, resident is still losing weight. Doctor has referred resident to specialty department for further testing. So, 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 deficiencies cited.the state’s words, verbatim · CDSS document, Aug 22, 2024 · control 21-AS-20240618094648

Type of visit: Office

Licensing Program Manager Victoria Bertozzi and Licensing Program Analyst Christi Coppo conducted an informal office meeting, and met with Administrator, Patrick Seawright and John O'Brien District Manager (DM) for licensee and Michelle Mainez COO of licensee. Informal meeting to address concerns identified by the Department during a recent Complaint Investigation. DM indicated they had lots of meetings about this incident and agree that the course of action taken by Admin was not appropriate and they have addressed it with Admin. Going forward, the staff have all been retrained about communicating about residents' care needs in order to prevent residents from experiencing pain unaddressed. Admin wants it noted that there was not any malice or purposeful neglect to not get the medical attention for R1. The complaint investigation revealed that a client was observed on with a “heat blister” on 2/12/2024 by facility staff. Staff documented the blister on the facility’s internal system and per interviews, Administrator was notified of the blister the same day. The Administrator did not seek medical treatment via the emergency room despite client presenting with a raised blister. Staff noted that on the NOC shift the client was “whining” during repositioning. On 2/13/2024, staff noted that they observed the blister had grown bigger, was red, and filled with liquid. Interviews conducted during investigation revealed that the blister ruptured on 2/14/2024. Administrator did not seek medical treatment via the emergency room when blister ruptured. LPM Bertozzi spoke with Administrator on 2/15/2024 around 2:00pm. Administrator told LPM that they had emailed the client’s doctor between 9:00am and 11:00am but was unsure if the doctor had responded. CCL staff advised the Administrator to seek emergency medical treatment for the client, but Administrator indicated that they were going to wait for the doctor to respond. Continued on LIC809C Continued from LIC809 LPM directed Administrator to call the doctor and notify the office staff to assist in expedited guidance from the doctor. Eventually, the client’s doctor directed the Administrator to seek emergency medical treatment, which they did on 2/15/2024 at approximately 4:54pm. LPM spoke directly with Administrator regarding a perceived refusal on the part of the Administrator to seek medical attention for the client. Administrator disagreed that they refused and indicated that they were unsure how to proceed as the injury was not something that they have previously encountered. Parties discussed the changes that facility has made to their protocols to ensure residents' needs are met timely as well as the interaction between the Administrator and CCL staff. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, May 29, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(a)(1) · Plan of correction due date: May 30, 2024

87405(d)(a) - (d)The administrator shall have the qualifications specified... (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not met as evidenced by: Based on CCL complaint inspection, the licensee did not comply with the section cited above in that facility Administrator did not seek timely medical attention for resident R1, which posed an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 29, 2024

Plan of correction: Admin to self-certify on LIC9098 that they have read regulation 87405 and licensee to submit updated protocol procedures including appropriate responses to types of injuries and the related medical response necessary by plan of correction due date.

Allegation investigated: Due to staff severe neglect resident sustained a blister on their leg Staff did not seek medical attention for resident in a timely manner

At approximately 9:00am, Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings regarding the above allegations and met with Patrick Seawright, Administrator. Due to staff severe neglect, resident sustained a blister on their leg – Complaint alleges that heating pads were brought to the facility by resident’s (R1’s) family member in mid to late January of 2024, and family member instructed staff to use them on R1 at night. On 2/12/2024, staff discovered that R1 had received a severe heat blister from the pads. Per CCL interview, resident’s family denied telling any staff to use the pads, stating that they explained how they (the family member) used the pads when the staff inquired. Identified staff denied inquiring about the pads and stated they did not use the pads on R1. Another staff indicated that they did use the pads after being instructed to use them by another staff, however, that staff, who provided instructions also denied using the pads. R1 was seen at the Hospital on 2/15/2024 where they were diagnosed with a second-degree burn. Continued on 9099C... Substantiated Continued from 9099... Staff did not seek medical attention for resident in a timely manner – Based on CCL Investigation, R1 was not treated for their burn until four days after it was first discovered by staff and only after the heat blister ruptured. R1’s blister was discovered on 2/12/2024, the incident causing the injury occurred on the PM shift on 2/11/2024, the heat blister ruptured on 2/14/2024, and R1 was first taken to the hospital on 2/15/2024. Based on observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Deficiencies cited on the attached LIC 9099D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **An immediate Civil Penalty in the total amount of $500 has been issued for a violation that resulted in the sickness or injury of a resident in care (See LIC-421IM) An additional civil penalty may be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).** Exit interview conducted with Administrator and a copy of this report was giventhe state’s words, verbatim · CDSS document, May 16, 2024 · control 21-AS-20240214082730

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 17, 2024

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement was not met by licensee as evidenced by: Based on investigation, interviews, photographic evidence, and observation of R1, due to staff severe neglect, resident sustained a blister on their leg, which posed an immediate health, safety, and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: Facility to submit detailed and specific plan to CCL indicating the steps that will be taken to assess and how they will address the care needs of residents, medical and otherwise, and how they will properly monitor residents to ensure proper and appropriate care is provided. **An immediate Civil Penalty in the total amount of $500 has been issued for a violation that resulted in the sickness or injury of a resident in care (See LIC-421IM)

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: May 17, 2024

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs… This requirement was not met by licensee as evidenced by: Based on CCL Investigation, R1 was not treated for their burn until four days after it was first discovered by staff and only after the heat blister ruptured.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: Facility to submit plan to CCL on how they will ensure all residents receive timely care, medical or otherwise, attention to their care needs, and that appropriate assistance and attention is provided at all times.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Patrick Seawright, Administrator. Facility currently has three (3) residents in care. Facility contact information was reviewed. Patrick Seawright Administrator Certificate 6039802740 expires 5/25/2024. At approximately 9:30am LPA and Administrator toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled. Kitchen drawer containing sharp knives was locked. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats but did not have non-skid backing. Per Title 22 regulation 87303(e)(5), Non-skid mats or strips shall be used in all bathtubs and showers, see Technical Violation. Water temperature in sink(s) accessible to residents in care measured at 106.7 and 107.5 degrees F, respectively, which is within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected November 2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested. Facility’s last quarterly disaster drill was conducted on December 14, 2023. Facility has a backup generator for use during a power outage. Fireplace in dining room not screened. Per Title 22 regulation 87307(d)(7) Fireplaces and open-faced heaters shall be adequately screened, see Technical Violation. Report continued on LIC 809C... Continued from 809... At approximately 11:00am LPA and Administrator conducted a review of 3 out of 3 resident records and 5 of 5 staff records. All required documents present. At approximately 1:00pm LPA and Administrator conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet in the living room. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Evidence of Liability Insurance Copy of current lease Surety Bond Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Dec 19, 2023

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.