Pine Ridge Terrace

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a case management visit and was greeted by conceirge. Administrator Donald Rodreick arrived later. On 9/3/26 CCL received an Incident Report indicating a medication error for resident (R1). Report indicates that on 8/30/26 R1 was administered Spironolactone in error (deficiency cited, see 809D). Once error was identified, R1 was immediately assessed. Per incident report, R1 denied experiencing any unusual symptoms. No adverse reactions observed. Per Incident Report, staff was to receive training to address medication error. Training to be conducted on the rights of medication administration. Med Techs and nurses were to receive training. During LPA visit, LPA met with Administrator and partially toured facility, touring the medication room for Memory Care (MC) and medication rooms for Assisted Living (AL) on both the 2nd and 3rd floors. LPA observed all three (3) medication rooms to be clean and sanitary. LPA met with Health Services Director (HSD), Allezmoy Bourque. LPA requested and reviewed R1's physician report, care plan, chart notes, medication administration records (MARs) and current medication orders. Admin provided LPA with Medication Management In-Service training documentation conducted on 9/8/26 and 9/9/26. LPA review of R1's chart notes reflect the reported medication error for R1. Chart notes indicate R1 did not report any adverse reactions nor were any adverse reactions observed by facility staff. LPA reviewed chart notes from 8/30/26-9/14/26. A civil penalty in the amount of $250 is being assessed today for repeat violations within a 12 month period (see LIC421FC). 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 22, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 23, 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 22, 2026

Plan of correction: Facility conducted medication training following the medication error. LPA received copies of training documentaiton while at facility. Deficiency cleared. **A civil penalty in the amount of $250 is being assessed today for repeat violations within a 12 month period (see LIC421FC)**

Allegation investigated: Staff do not meet residents' needs in a timely manner due to lack of staff

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 5/11/2026 at approximately 9:20am, and met with Don Rodreick, Administator/ED. Reporting party alleges that "staff do not meet residents needs in a timely manner due to lack of staff". LPA reviewed resident records, including medical records, care plan, medical assessment, and admission documents. LPA reviewed facility records, including medication records/MARS, care assessments, and staffing schedules for the memory care unit. LPA conducted interviews with staff, and other related parties. The investigation revealed that there are days in the month that direct care staff have called off work and the staff's shift was not covered, leaving the shift short one caregiver. The 6:00am to 2:00pm, and the 2:00pm to 10:00pm, shifts have three (3) direct caregivers, and a medication-thechnician scheduled to work, and the 10:00pm to 6:00am has two (2) direct caregivers on shift;This shift has a floating medication-technician that assists residents with medications in assisted living and memory care. Continued on LIC9099C.. Substantiated In review of caregivers on shift in staff work schedules provided to the LPA, the following was identified: On 2/16, 4/20, and 4/27, on the 6am to 2pm shift, there were only two (2) direct caregivers on shift. On 2/8, 2/9, 2/10, 2/11, 2/12, 2/15, 2/16, 2/17, 2/18, 2/19, 3/5, 3/6, and 3/9 on the 2:pm to 10pm shift, there were only two (2) direct caregivers on shift. On 3/7, on the 2pm to 10pm shift, there were only two (2) direct caregivers on shift. If a medication -technician calls out in memory care, the assisted living medication -technician will cover the memory care resident medications. Interviews conducted by the LPA, 1 through 9, supported that when the shift is down a caregiver it makes it difficult for some job duties/care needs to be done in a timely manner for residents in care. LPA observed a resident R6 who had their lower half of their body sliding out of their low bed, this was on 3/24/26 inspection, the resident was observed to need care, hygiene care, and dressing, their morning/late morning adls, for the day. LPA discussed this with the Administrator; The Administrator had staff go and assist R6 up, and with their ADLs. The LPA observed R6 later in the tour, to be cleaned, hair combed, appropriately dressed, and in the activity area with other residents. Per interviews, caregivers are expected to serve the meals to the memory care residents, clean the dining room, counters, gather all dishes, silverware, and clean the windows and floors from all meals. The LPA identified that the dining room in the memory care unit was dirty, the glass windows, and door were dirty with smudged prints and grime, the floor covered with dirt, grime, crumbs, food, and some garbage. The LPAs shoes were sticking to the floor as it was dirty and very sticky. The memory care laundry room was dirty, floor dirty with garbage, and with torn flooring, Inspection date of 3/24/26 the laundry room sink was taken out, and a bucket was hanging off the faucet pipe. The laundry room is not in good repair, though it now has a sink put back in. LPA observed large pieces of lint on the small side patio table and chair outside in the memory care courtyard. The hallways, activity rooms, and the medication room need a good floor cleaning, swept and mopped, including in the doorways, from garbage and debris seen in doorways, on the floors, and under desks/counter. LPA obtained pictures of the above items mentioned in the report. This will be cited in a case management report, LIC809/809D, dated 5/11/26. Continued on LIC9099C.. Per investigation staff that call off shift in the memory care in the 6am to 2pm, and the 2pm to 10pm shifts are not covered regularly as needed to meet all job duties/care needs required by the staff to ensure residents needs are met in a timely manner. Based on the investigation, record reviews, and interviews conducted, there was sufficient information obtained to support that a violation had occurred regarding "staff do not meet residents' needs in a timely manner due to lack of staff". This deficiency will be cited, 87411(a) Personnel Requirements - General - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Appeal rights provided with report. Exit interview conducted with Don Rodreick, Administator/ED.the state’s words, verbatim · CDSS document, May 11, 2026 · control 21-AS-20260316152654

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: May 26, 2026

87411(a) Personnel Requirements - General - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Sufficient support staff shall be employed to ensure provision of personal assistance and care as required . Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds.This requirement was not met as evidenced by: Per investigation staff that call off shift in the memory care in the 6am to 2pm, and the 2pm to 10pm shifts are not covered regularly as needed to meet all job duties/care needs required by the staff to ensure residents needs are met in a timely manner. This is a risk to personal rights of the residents in care and/or a health & safety risk.the state’s words, verbatim · CDSS document, May 11, 2026

Plan of correction: Administrator to ensure that all shifts in the memory care are staffed as needed and required to meet all residents needs in a timely manner. Ensure that the facility has sufficient staffing to meet other job duties that may not be direct care duties that the care staff can't complete due to their responsibilities with residents. Please assess the needed staff for memory care, and a plan in filling scheduled staff that call out. Submit plan of correction and updated staff schedule, and duties of the memory care staff, ensuring sufficient staffing to meet all duties required by staff in memory care. POC due 5/26/26.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alviso conducted a case management inspection, on 5/11/2026 at approximately 1:00pm, and met with Don Rodreick, Administator/ED. This case management inspection is being conducted to cite deficiencies observed during LPA's complaint investigation, 21-AS-20260316152654. Per interviews, conducted with staff, caregivers are expected to serve the meals to the memory care residents, clean the dining room, counters, gather all dishes, silverware, and clean the windows and floors from all meals. The LPA identified that the dining room in the memory care unit was dirty, the glass windows, and door were dirty with smudged prints and grime, the floor covered with dirt, grime, crumbs, food, and some garbage. The LPAs shoes were sticking to the floor as it was dirty and very sticky. The memory care laundry room was dirty, floor dirty with garbage, and with torn flooring, Inspection date of 3/24/26 the laundry room sink was taken out, and a bucket was hanging off the faucet pipe. The laundry room is not in good repair, though it now has a sink put back in. LPA observed large pieces of lint on the small side patio table and chair outside in the memory care courtyard. The hallways, activity rooms, and the medication room need a good floor cleaning, swept and mopped, including in the doorways, from garbage and debris seen in doorways, on the floors, and under desks/counter. LPA obtained pictures of the above items mentioned in the report. This deficiency will be cited, 87303(a) Maintenance and Operation- The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors, see LIC809D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights provided with report. Exit interview conducted with Don Rodreick-Administator/ED.the state’s words, verbatim · CDSS document, May 11, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 26, 2026

87303(a) Maintenance and Operation- The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. The LPA identified that the dining room in the memory care unit was dirty, the glass windows, and door were dirty with smudged prints and grime, the floor covered with dirt, grime, crumbs, food, and some garbage. The LPAs shoes were sticking to the floor as it was dirty and very sticky. The memory care laundry room was dirty, floor dirty with garbage, and with torn flooring, Inspection date of 3/24/26 the laundry room sink was taken out, and a bucket was hanging off the faucet pipe. The laundry room is not in good repair, though it now has a sink put back in. LPA observed large pieces of lint on the small side patio table and chair outside in the memory care courtyard. The hallways, activity rooms, and the medication room need a good floor cleaning, swept and mopped, including in the doorways, from garbage and debris seen in doorways, on the floors, and under desks/counter. This is a risk to the health & safety of residents.the state’s words, verbatim · CDSS document, May 11, 2026

Plan of correction: Administrator will ensure the memory care unit is clean, safe, sanitary, and in good repair as required by regulation. Ensure staffing to clean and maintain all areas in the required manner per the 87303(a) regulation. Submit plan on correcting all items mentioned in the report. Submit correction plan, and continued maintainance plan for future compliance. POC due 5/26/26

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Cuadra arrived unannounced to conduct a Required -1 Year visit, and met with Administrator Karina Tapia. Facility has an approved dementia care plan. There are 77 residents in Assisted Living and 22 residents in Memory Care for a total of 99 residents in care. There are residents receiving hospice care services within the approved hospice waiver. Required postings were observed. LPA/Administrator toured the facility which included an inspection of assisted living and memory care, all common areas, hallways, and bathrooms observed had sufficient lighting. Residents rooms are furnished per regulation. The memory care unit is on a delayed egress system and a locked perimeter courtyard for resident use, which it was approved in their fire clearance. There are evacuation chairs located at each stairwell. The elevators were last inspected on 7/16/25 and permit expires on 7/16/26. The facility was a comfortable temperature. Passageways were free of obstructions. Facility has a sufficient supply of cleaners, hygiene items and paper products. Multiple first aid kits were observed. A call button is located in each bathroom, LPA tested the call system in resident's rooms and staff response time was under three minutes. A tour and inspection of the kitchens and dining areas were found to be clean and sanitary. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. Refrigerators and freezers were at required temperatures. Prepared and left over foods were covered and labeled. Menu includes a wide variety of foods from all of the food groups. A board in the kitchen has written instructions for residents with food allergies and restricted diets. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. The facility has a generator in case of power outages. At approximate 9:28am and 9:43am, LPA/Administrator observed one maintenance shop and two laundry rooms located in assisted living unit were unlocked. Other cleaning products that were observed on the floor were supervised and/or locked carts. Continued on LIC 809-C... Continued from LIC809... Residents were observed participating in group activities in common areas. There are activities written on a board specified for both assisted living and memory care engagement. The last fire drill was conducted December 2025. The fire alarm and sprinkler system was last inspected October 2025. Fire extinguishers were observed to be last charged on 10/2025. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected October 2025. Water temperatures measured at between 115.7 and 118.6 degrees (F) which is within acceptable range of 105 to 120 degrees F. Bathrooms have non-skid surfaces and grab bars at the toilet and shower areas. All medications were all locked and inaccessible to residents in care. - At 10:20 AM, LPA conducted a file review of ten staff and ten residents. LPA observed three out of ten staff individuals (I1, I2 & I3) were fingerprint cleared, but their fingerprints have not been transferred and associated to the facility. LPA informed Administrator that staff (I1, I2 & I3) are not associated to facility and should never be working and providing care to residents prior to a criminal record clearance transfer. Civil penalties are being assessed in the amount of $100 per person for a total amount of $300 for allowing a person to work, reside or volunteer in the facility without a fingerprint clearance transfer and association. One out of ten staff (S1) do not have a health screening form on file including their TB test (technical violation issued). Five out of ten staff (S3, S4, S5, S7 & S9) do not have current 1st aid or CPR certificates updated, but there is at least one staff on shift that has a valid CPR/1st aid certificate (technical violation issued). Six out of ten staff (S1, S2, S4, S6, S7 & S8) have not completed all required training hours. According to Administrator, effective on 6/30/25 there was a change of management that resulted in a different vendor for staff training and previous management kept training records (technical violation issued). Residents receiving hospice services had a care plan that appears to be accurate to services being provided. All residents' care plans seems to have a person-centered approach and they are updated. Medical assessments are current and included a description of any known behavioral expression. Karina Tapia, administrator certificate 7029240740 expires on 11/20/2026. Medications and medication records were reviewed. Annual fees are not current, but LPA was informed by the operations administration director that they have the invoice on hand and the financial department is working on submitting a payment timely. Administrator agrees to submit updated documents by 2/6/26: LIC500Personnel Report & Liability Insurance. Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, and the Health and Safety Code. Civil penalties in the amount of $300.00 is being assessed due to staff not being associated to facility. Appeal Rights Given. Exit interview conducted with Administrator and copy of this report was given.the state’s words, verbatim · CDSS document, Jan 15, 2026

The state marks this report as 8 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Facility staff do not respond to call bell in a timely manner.

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 12/4/25 at approximately 10:00am, and met with Karina Tapia, Administrator, and Cheyenne Flores, LVN/Health Services Director Reporting party alleges that "facility staff do not respond to call bell in a timely manner." LPA reviewed resident records, including care plan, medical assessment, and admission documents. LPA requested a copy of the alarm pendant report for R1's room, for month of October 2025; Staff provided the LPA with the copies requested. LPA interviewed staff, and other related parties regarding the allegation. The investigation revealed that per review of alarm event report on R1's pendant for the month of October 2025, the following recorded dates, times, and elapsed time, of minutes & seconds, till staff responded to R1's call pendant read as follows:10/4 at 5:02am, elapsed time 24:23,10/4 at 2:09pm, elapsed time 17:47, Continued on LIC9099C.. Substantiated on 10/5 at 2:49pm, elapsed time 21:15, on 10/8 at 2:25pm, elapsed time 18:06, on 10/10 at 8:15am, elapsed time 16:53, on 10/12 at 4:13pm, elapsed time 22:36, and on 10/17 at 3:50pm, elapsed time 24:19. There was sufficient information obtained in the investigation to support a violation had occurred. LPA reviewed the alarm report and documented the above dates/times that staff didn't respond within a timely manner; Facility to ensure a timely response to call pendants for whatever is needed by the resident, including to ensure there is not an emergency response needed/required, such as 911 call out for the resident or incontinent care needs and/or medication assistance. Based on record reviews, staff interviews, and interviews with other related parties, the allegation "facility staff do not respond to call bell in a timely manner." is substantiated. Deficiency will be cited, 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities- In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs, see LIC9099D. The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Appeal rights provided with report. Exit interview conducted with Cheyenne Flores, LVN/Health Services Director.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 21-AS-20251020095513

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 19, 2025

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities- In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Per review of alarm event report on R1's pendant for the month of 10/2025, the following recorded dates, times, and elapsed time until staff responded to R1's call pendant, LPA documented calls that had a wait from 15 minutes to over 20 minutes for some, on 10/4 twice, 10/5, 10/8, 10/10, 10/12, and 10/17, see LIC9099. Facility staff failed to respond in a timely manner to R1's pendant calls listed. This is a risk to resident's personal rights & a risk to resident's health & safety.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: Licensee/Administrator to ensure that facility staff/direct caregivers are responding to all resident pendant calls, on all shifts, in a timely manner. Staff to respond in a timely manner to help ensure residents' needs are met as required, including emergency response/911 to be called if needed. Staff to be in-serviced in residents 'rights, and staff responsibility in answering pendant calls timely for all residents in care. Submit proof of training with direct care staff, all staff that answer to call pendants; Submit a plan of future compliance regarding the regulation and call pendant response by staff. POC due 12/19/25.

Allegation investigated: Staff violated resident's personal rights

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 11/6/25 at approximately 9:45am, and met with Karina Tapia, Administrator, and Cheyenne Flores, LVN/Health Services Director Reporting party alleges that "staff violated resident's personal rights." LPA reviewed resident records, care plan, medical assessment, medication records/medical records, and admission documents. LPA interviewed staff, and other related parties regarding the allegation. LPA obtained two photos that had been taken, by S3/staff member, of resident R1 who had fallen on the ground in their apartment unit. S3 took the pictures of R1, with their personal cell phone, prior to assisting the resident off the floor, and providing needed care to R1. The photos of R1 were identified to be taken on 7/24, during S3's shift, per date and time stamp of photo; LPA observed S3's cell phone number as the phone number that sent the pictures to the resident's cell phone days later after the incident. Substantiated Per investigation and interviews, the resident/R1 photos are found to be personal, confidential, humiliating, and violate R1’s personal rights. LPA has copies of photos for the file. Per review of records, S3 was being written up by administration staff, for resident privacy and dignity violations of R1, as well as for a HIPPA violation; There was sufficient information obtained in the investigation to support a violation had occurred. Based on record reviews, obtained photos, staff interviews, and interviews with other related parties, the allegation "staff violated resident's personal rights" is substantiated. Deficiency will be cited, 87468.2(a)(1)(3) Additional Personal Rights of Residents in Privately Operated Facilities- Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, see LIC9099D. The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Appeal rights provided with report. Exit interview conducted with Cheyenne Flores, LVN/Health Services Director. LPA was not able to obtain any supporting information of inappropriate comments being made by staff to resident/R1 and/or information of staff not providing incontinent care and violating resident rights with incontinent care services. There was no specific date and/or time of incidents of alleged violations that was able to be provided. LPA discussed and reviewed regulations with the Administrator regarding, personal rights of residents in care, and required training for all direct care staff. No information was obtained to support that violations of "staff did not assist a resident with incontinent care needs, and staff made an inappropriate comment towards resident." had occurred. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations are Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted with Cheyenne Flores, LVN/Health Services Director.the state’s words, verbatim · CDSS document, Nov 6, 2025 · control 21-AS-20250918163816

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1)(3) · Plan of correction due date: Nov 21, 2025

87468.2(a)(1)(3) Additional Personal Rights of Residents in Privately Operated Facilities- Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature. This requirement was not met as evidenced by: LPA obtained two photos that had been taken, by S3/staff member, of resident R1 who had fallen on the ground in their apartment unit. S3 took the pictures of R1, with their personal cell phone, prior to assisting the resident off the floor, and providing needed care. stamp, and with S3's personal phone. Per investigation, and interviews, the resident/R1 photos are found to be personal, confidential, humiliating, and violate R1’s personal rights. LPA has copies of photos for the file. This is a violation of resident's personal rights.the state’s words, verbatim · CDSS document, Nov 6, 2025

Plan of correction: Licensee/Administrator to ensure all staff do not violate personal rights of residents’ in care. Staff are to be in-serviced on “Elder Abuse” training, and “Personal Rights of Residents” training. Submit proof of training, and plan of correction of the deficiency citation by 11/21/2025.

Type of visit: Case Management - Incident

Licensing Prigram Analyst (LPA) Alviso conducted a case management inspection, on 11/6/25 at approximately 9:45am, and met with Administrator Karina Tapia, and Cheyenne Flores, LVN/Health Services Director. The case management is being conducted to review three (3) resident incident reports the facility Administrator reported to the Department. An incident report was received on R1 & R3 regarding reported of abuse by R3. A required SOC341, suspected elder/adult abuse report was reported as required. The Department received both reports. Per interview and review of records, the facility addressed the reported resident incident appropriately. Administration staff is continuing to follow-up to help ensure residents', R1 & R3's, health and safety. Facility will update the Department when required/as required. Incident regarding R2 who AWOL the memory care unit from the patio/courtyard door to the outside;The door is an egress exit, pressing on it for time required will release it, alarm sounded which alerted staff, who found R2 in the parking lot,this occurred on 10/31, at 5am. Incident of R2 on 11/2 AWOL out the memory care unit door that is inside the building leading into the assisted living area. R2 approached the front lobby area, and was redirected by staff back to the memory care. Only staff have the key code to the memory care door leading into the assisted living area. In review of the incidents of R2 that occurred on 10/31 & 11/2, a deficiency will be cited, 87705(e)(7) Care of Persons with Dementia- Licensees that use delayed egress devices on exterior doors and perimeter fence gates shall meet the following initial and continuing requirements: Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents, including staff needed to escort residents who need supervision to leave the facility, see LIC809D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights provided with report. Exit interview conducted with Cheyenne Flores, LVN/Health Services Director.the state’s words, verbatim · CDSS document, Nov 6, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(e)(7) · Plan of correction due date: Nov 21, 2025

87705(e)(7) Care of Persons with Dementia- Licensees that use delayed egress devices on exterior doors and perimeter fence gates shall meet the following initial and continuing requirements: Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents,, including staff needed to escort residents who need supervision to leave the facility. This requirement was not met as evidenced by: Incident regarding R2 who AWOL the memory care unit from the patio/courtyard door to the outside; The door is an egress exit, pressing on it for time required will release it, alarm sounded which alerted staff, who found R2 in the parking lot,this occurred on 10/31, at 5am. Incident of R2 on 11/2 AWOL out the memory care unit door that is inside the building leading into the assisted living area. R2 approached the front lobby area, and was redirected by staff back to the memory care. Only staff have the key code to the memory care unit door in the building. This is a health & safety risk for the resident.the state’s words, verbatim · CDSS document, Nov 6, 2025

Plan of correction: Licensee/Administrator to ensure that memory care unit key code door is monitored to fully close when entering andor leaving the unit to ensure residents' aren't able to go out the door without staff's knowledge. Ensure sufficient staffing, qualified with training regarding the memory care policy and procedures of residents seeking an exit, wandering and/or AWOL the facility. In-service with all staff the policy and procedures of the memory care doors and their alarm features. Proof of training to be submitted by 11/21/25. POC due by 11/21/25.

Allegation investigated: Staff touched resident in an inappropriate manner

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 9/11/25 at approximately 10:20am, and met with Administrator Karina Tapia, and Cheyenne Flores, LVN/Health Services Director. Reporting party alleges “staff touched resident in an inappropriate manner “. LPA interviewed staff, Administrator Karina Tapia. The investigation revealed that resident (R1) is not a resident of the assisted living residential care facility for the elderly-license #496804280. R1 was identified by name to have been a patient in the skilled nursing facility building across from the assisted living building. The Arbol skilled nursing facility is not part of the assisted living license. LPA will cross report, reporting party’s information/allegations to the appropriate investigating agency, the CA Department of Public Health. Per LPA’s investigation, the allegation of “staff touched resident in an inappropriate manner” is Unfounded, R1 is not a resident of Pine Ridge Terrace assisted living. The Department/Community Care Licensing has no jurisdiction over the Arbol Skilled Nursing Care facility. Unfoundedthe state’s words, verbatim · CDSS document, Sep 11, 2025 · control 21-AS-20250910082154

Type of visit: Case Management - Incident

Licensing Prigram Analyst (LPA) Alviso conducted a case management inspection, on 9/11/25 at approximately 10:20am, and met with Administrator Karina Tapia, and Cheyenne Flores, LVN/Health Services Director. The case management is being conducted to review a resident incident, and death report, the facility Administrator reported to the Department. LPA reviewed records on former resident (R1).and obtained requested copies of documentation/records. LPA reviewed care plan, assessments, progress notes, admission documents, medication list, and medical documentation, including Dr's Orders. No deficiencies were cited today.the state’s words, verbatim · CDSS document, Sep 11, 2025

Allegation investigated: Staff left resident in a soiled diaper for a long period of time Staff are not ensuring that resident's glucose levels are checked

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 9/4/25 at approximately 10:00am, and met with Administrator Karina Tapia and Cheyenne Flores LVN, Health Services Director. Reporting party alleges that "staff left resident in a soiled diaper for a long period of time, and staff are not ensuring that resident's glucose levels are checked". LPA reviewed resident (R1) records, including medical assessment, appraisal, medication list, Dr's Orders, progress notes/log, and R1's care plan. The LPA conducted interviews with staff, and other related parties regarding the allegations. Per review of resident records, facility records, and conducted interviews,the Investigation revealed that R1's care plan does address incontinent care, including the needed checks for incontinent care. R1 does have a call alert pendant to use as needed, and R1 does understand how to use this device. There were no specific dates/times provided of R1's incontinent needs not being met that were reported. There was no information obtained that care staff are not providing incontinent checks on R1 as needed. No sufficient information was obtained to support that a violation occurred. Continued on LIC9099C... Unsubstantiated Per record reviews, and conducted interviews, R1's glucose checks are being done by the Nursing staff as required before each insulin dose time, three (3) times a day, which includes an additional order of insulin that is provided twice (2) a day within the time of the first insulin order above. There is a PRN as needed insulin order, and if needed this would be provided to R1. Insulin is provided on a sliding scale, which means the Nurse must do a glucose check in order to provide the specific needed dosage to R1. Per record review there is no Dr's Order for late night and/or through the night glucose checks. R1 does have a small device on their arm that provides blood sugar levels/readings. Resident is alert and able to use pendant to alert staff as needed. There was no information obtained that care staff are not providing glucose checks as needed for R1. No sufficient information was obtained to support that a violation occurred. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation "staff left resident in a soiled diaper for a long period of time, and staff are not ensuring that resident's glucose levels are checked" are Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies cited. Exit interview was conducted with the Administrator Karina Tapia.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 21-AS-20250707084206

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Alviso, conducted a pre-licensing inspection, on1/10/25 at approximately 12:50pm, and met with Administrator Karina Tapia, Administrator. Component III orientation was completed with Administrator Karina Tapia, today 1/10/25. Applicant has a fire clearance approval for one hundred and ten (110) non-ambulatory, of which 30 may be bedridden. The applicant has been approved for twenty-five (25) hospice residents. The facility has an approved dementia plan of operation. The facility has a required infection control plan and a required disaster emergency plan. The facility site consists of a three story assisted living building, which includes a memory care unit. Memory care unit has delayed egress, and a locked perimeter courtyard for resident use. LPA observed sufficient furnishings on-site throughout the facility for resident use. The kitchen has a sufficient supply of food for residents in care. The grounds were free of any apparent hazards, and exits were clear. No bodies of water. No firearms. LPA observed medication room for assisted living area, and a medication room in the memory care unit. Facility had emergency supplies, including food and water, to meet requirement for the 72 hour shelter in place. Postings noted to be current and in compliance with regulations, including the complaint poster and ombudsman poster. Fire extinguishers were serviced and tagged as required. Hot water was checked at 110.6 degrees Fahrenheit. There are deficiencies that were observed during the pre-licensing inspection, these will be cited on the current license, Arbol Residences of Santa Rosa- 496803905, see case management report dated, 1/10/25. Once all deficiencies cited are corrected by current licensee, and plan of corrections (POCs) are submitted to the Department as required, LPA will review corrections, and may make an inspection visit to clear POCs. Once all deficiencies are cleared the LPA will notify the application unit The application unit analyst will notify the applicant of the status of their application.the state’s words, verbatim · CDSS document, Jan 10, 2025

Type of visit: Office

Facility Type: Residential Care Facility for the Elderly Application Type: Change of Ownership Capacity: 110 Census (if any clients in care): 91 COMP II Participants: KARINA TAPIA, QUINTIN KING Interview Method: Telephone interview On December 12, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Dec 12, 2024