Plymouth Village of Redlands

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Edith Conchas and Renese Howell-Small made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Michael Harrison, Executive Director, and discussed the purpose of the visit. The facility is a Continuing Care Retirement Community with independent homes, a two story assisted living unit, and a memory care unit. The facility has a license capacity of (303) residents and a hospice waiver for seven (7) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has sufficient indoor and outdoor space for resident activities. The memory care outdoor activity space is enclosed by perimeter fence gates approved by the Fire Marshall. LPA took a tour of the facility and the resident’s bathrooms were inspected at random and operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured between 105 to 120 degrees F. The resident’s bedrooms were inspected at random and have sufficient lighting and furniture is in good repair. The facility has operating carbon monoxide alarms, telephone service, laundry equipment and signal system. The facility has sufficient linen, towels, and personal hygiene items for residents. Continued on LIC809-C The facility has posted in resident common areas, The Community Care Licensing complaint posters, Ombudsman posters, facility sketches, and resident monthly activities. Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerators and freezers are operating in a healthful manner. Pesticides and other cleaning solutions were kept locked and stored away from food areas. The facility has posted menus and sufficient dining areas for residents. Care & Supervision: The facility has 24-hour/7 days a week care staff and have in-house drivers to transport the residents. LPA observed several staff assisting with resident care, food service, maintenance and housekeeping. Record Review: The facility conducted a Fire drill on 10/13/2025 and Disaster drill last conducted on 9/26/2025. Emergency Disaster Plan was last updated on 4/23/2025 due to no changes. Facility has a Manual Fire Dampers system last inspected on 11/20/2024 and next inspection due date is on 11/20/2028. The facilities Tamper switch and Water flow device inspection was tested 12/10/2024. Six (6) staff files were reviewed at random and were observed to be complete and included criminal record clearances or exemptions through the Department. Six (6) residents files reviewed at random were observed to be complete. Medical Related Services: All medication was centrally stored and kept locked in the medication room and appeared to be dispensed as prescribed by their physicians. Based on LPA observations and file review, the facility is in compliance with Title 22 regulations and no deficiencies were cited during today's visit. An exit interview was conducted at the conclusion of the visit and a copy of this report was provided to the Executive Director at the conclusion of the visit with appeal rights..the state’s words, verbatim · CDSS document, Nov 17, 2025

Allegation investigated: Resident sustained multiple falls at the facility Facility staff did not notify resident's representative of a change in the resident's condition Staff left resident in soiled clothing for an extended period of time Staff did not ensure that resident had clean linens Facility was malodorous Facility did not communicate with resident's representatives in a timely manner Facility did not keep resident's records up to date Facility did not provide resident with a written notice of eviction

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to concluded a complaint investigation regarding the above allegations. LPA Prieto met with Executive Director Michael Harrison and explained the elements of the complaint. Allegation #1 - Resident records reveal that resident #1 (R1) had falls at the facility and were documented. LPA obtained records of falls that were unwitnessed. Facility was in contact with R1's family members to address a change of condition and behaviors relating falls. Allegation #2 - LPA obtained resident notes and email communication regarding R1's change of condition with R1's family members regarding the change in resident condition. Allegation #3 - Staff records show they have been addressing R1's incontinence care needs. Records also reveal that R1 laundry service was being addressed with change of linens and resident clothing once they Unsubstantiated were made aware of the situation. Allegation #4 - Records also reveal that R1's laundry service was being addressed with change of linens and resident clothing when staff was made aware of the situation Allegation #5 - LPA toured facility at time of initial investigation and found the facility to be clean, hallways free on obstruction, with no foul odors. Allegation #6 - LPA obtained R1's Progress notes that reveal timely communication with R1's family members pertaining to care plan meeting, increased safety checks and increase behaviors. Allegation #7 - All records obtained during this investigation, pertaining resident care and family communication were current and up to date. Allegation #8 - Email documentation was obtained revealing that R1 was not evicted but family members moving R1 from the facility by their accord. Records also reveal that the those family members requested specific items from the facility such as medical assessments and medication, which records reveal that those items were provided by facility staff. Based on the information obtained there is not enough evidence to support the allegations made in this complaint. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was singed by LPA Prieto and Executive Director Harrison and a copy was left with the facility.the state’s words, verbatim · CDSS document, Sep 11, 2025 · control 18-AS-20211018152516

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Michael Harrison, Executive Director, and discussed the purpose of the visit. The facility is a Continuing Care Retirement Community with independent homes, a two story assisted living unit, and a memory care unit. The facility has a license capacity of (303) residents and a hospice waiver for (5) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has sufficient indoor and outdoor space for resident activities. The memory care outdoor activity space is enclosed by perimeter fence gates approved by fire marshall. Five (5 ) Resident’s bathrooms inspected at random were operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured 105 to 111 degrees F. Five (5) Resident’s bedrooms inspected at random have sufficient lighting and furniture in good repair. The facility has operating carbon monoxide alarms, telephone service, laundry equipment and signal system. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in resident common areas, Community Care Licensing complaint posters, Ombudsman posters, facility sketches, and resident monthly activities. Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerators and freezers are operating in a healthful manner. Pesticides and other cleaning solutions were kept locked and stored away from food areas. The facility has an onsite Dietician, posted menus and sufficient dining areas for residents. Care & Supervision: The facility has 24-hour/7 days a week care staff. LPA observed several staff assisting with resident care, food service, maintenance and housekeeping. Record Review: The facility conducted a fire drill on 12/08/23. Five (5) staff files reviewed at random were observed to be complete and included criminal record clearances or exemptions through the Department. Five (5) residents files reviewed at random were observed to be complete. Medical Related Services: All medication was centrally stored and kept locked in the medication room and appeared to be dispensed as prescribed by their physicians. Based on LPA observations and file review, the facility was in compliance with Title 22 regulations and no deficiencies were cited during today's visit. An exit interview was conducted at the conclusion of the visit and a copy of this report was provided to the Executive Director at the conclusion of the visit with appeal rights..the state’s words, verbatim · CDSS document, Dec 31, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Michael Harrison, Executive Director, and discussed the purpose of the visit. The facility is a Continuing Care Retirement Community with independent homes, a two story assisted living unit, and a memory care unit. The facility has a license capacity of (303) residents and a hospice waiver for (5) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has sufficient indoor and outdoor space for resident activities. The memory care outdoor activity space is enclosed by perimeter fence gates approved by fire marshall. Twelve (12) Resident’s bathrooms inspected at random were operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured 105 to 111 degrees F. (12) Resident’s bedrooms inspected at random have sufficient lighting and furniture in good repair. The facility has operating carbon monoxide alarms, telephone service, laundry equipment and signal system. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in resident common areas, Community Care Licensing complaint posters, Ombudsman posters, facility sketches, and resident monthly activities. Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerators and freezers are operating in a healthful manner. Pesticides and other cleaning solutions were kept locked and stored away from food areas. The facility has an onsite Dietician, posted menus and sufficient dining areas for residents. Care & Supervision: The facility has 24-hour/7 days a week care staff. LPA observed several staff assisting with resident care, food service, maintenance and housekeeping. Record Review: The facility conducted a fire drill on 12/08/23. (12) staff files reviewed at random were observed to be complete and included criminal record clearances or exemptions through the Department. (12) resident files reviewed at random were observed to be complete. Medical Related Services: All medication was centrally stored and kept locked in the medication room. Based on LPA observations and file review, the facility was in compliance with Title 22 regulations and no deficiencies were cited during today's visit. An exit interview was conducted at the conclusion of the visit and a copy of this report was provided to the Executive Director at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 23, 2024