Primavera Gardens

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. The purpose of this visit it deliver the final report on a case management that was initiated on 08/25/2025 regarding an elopement that occurred on 08/20/2025. LPA met with Administrator, Lisa Lanford. On 08/21/2025, the Department received a verbal report regarding resident (R1) who eloped from the facility on 08/20/2025. It was reported that R1 was found by a neighbor around the corner of the facility (about 450-500 feet away) around 2:00PM. The neighbor called 911 and when 911 arrived, R1 was observed disoriented and was taken to the hospital where it was found that R1 was diagnosed with an infection. It was stated that R1 did not sustain any injuries during the elopement. Based on interview with staff (S1), around 4:15PM it was reported by another staff (S2) that R1 was missing when they were gathering all the residents for dinner time. Staff immediately went to look for R1 in all the rooms, interior and exterior of the facility but was unable to location him/her. Around 4:25PM, S1 called 911 and reported a missing resident. S1 states that while walking around the neighborhood, the police was driving by and informed S1 that R1 was found after 2:04PM and was found with no injuries. S1 states that R1 was sent to the hospital by the police due to confusion and unable to describe what happened. S1 stated that R1 returned to the facility on the same day. Page 1 of 2. S1 stated to believe that R1 exited through the main entrance which is unlocked and does not alarm during the day. S1 stated that this was the first time this happened with R1, as R1 does not have any history of elopement. S1 denied any other residents having a history of elopement. LPA observed that there are cameras throughout the common areas. S1 stated to have went through all the camera footage and did not find footage of R1 leaving the facility. Based on record review, R1 diagnosed with a neurocognitive disorder and is not able to leave the facility unassisted. After the incident, the Administrator updated R1's appraisal/needs and services plan to include the change of behaviors after the elopement. The Administrator also provided staff with an in-service training on topics of elopement and behavior management. Going forward, the Administrator will always have a staff standing in the common areas which is facing the main entrance to supervise the residents and main entrance. Administrator states the main entrance door will continue to be unlocked and not alarmed because they have many visitors throughout the day going in and out of the facility. The Administrator states future plans to install an electric gate that will require a code to enter. Based on the facility's compliance history, the facility does not have any reported history of resident's eloping. No deficiencies were cited per California Code of Regulations, Title 22. A technical violation was provided per Title 22 Section 87219(i). This report was reviewed with Administrator, Lisa Lanford and a copy of the report was provided. Page 2 of 2.the state’s words, verbatim · CDSS document, Oct 2, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's required 1 year annual inspection. LPA met with Administrator, Lisa Lanford. The facility is currently undergoing a change of ownership and the new owner has submitted an application to the Department which is currently pending. All residents, family and staff were made aware of the upcoming change. During visit, LPA toured the facility with ADM to include all resident bedrooms, bathrooms, shower room, staff lounge, dining room, living room, kitchen, and laundry room. Facility temperature maintained at 70 degrees F. Emergency exit doors observed with door alarms. 1 out of 3 of the door alarms which was next to bedroom #1 observed not operable. During visit, the maintenance personnel replaced the battery of the door alarm in which LPA observed the door alarm was operable. Fire extinguisher last serviced on 10/24/2024. Facility equipped with carbon monoxide detectors in the kitchen and hallways. All resident bedrooms equipped with beds, linens, night stands, dressers, lidded trash bins, and adequate lighting. Residents whose beds are equipped with half rails has a physician order on file for the use of half rails. Page 1 of 3. LPA measured the hot water temperature in bedroom #1. LPA observed the sink in bedroom #1 was not properly draining causing the sink to be clogged. The maintenance personnel fixed the sink drainage during visit. The hot water temperature was measured at 119 degrees F. The hot water temperature in bedroom #9 measured at 133.7 degrees F. Hot water temperature in bedroom #10 measured at 126.5 degrees F. During visit, the maintenance personnel attempted to lower the hot water temperature but then states the knob to adjust the water temperature is broken. The maintenance personnel states to have called a plumber in which the plumber is scheduled to come to the facility the morning of 09/18/2025. In the meantime, the ADM states a plan to measure the hot water temperature in all bathroom sinks and shower room and place caution signs next to the sinks whose hot water temperature exceeds more than 120 degrees F, while the facility is waiting to lower the hot water temperature. A Type A deficiency is being cited today per Title 22 Section 87303(e)(2) for the hot water temperature exceeding more than 120 degrees F in bedroom #9 and #10. LPA toured the kitchen area. LPA observed a perishable food supply of at least 2 days and a nonperishable food supply of 7 days. Toxins and chemicals are stored separately from the food supply. LPA observed the pilot light of the gas stove is left continuously on. ADM states the brand of the stove is designed to have the pilot light left of on continuously. LPA advised of safety concerns as there were plastic seasoning containers above the stove where the pilot light was on. ADM stated understanding. During visit, the maintenance personnel placed a carbon monoxide detector in the kitchen area. Refrigerator temperatures maintained at 36 degrees F. Freezer temperature maintained at 0 degrees F. LPA toured the resident dining area. LPA observed a wooden plank in the track of the sliding glass door obstructing the sliding glass door in the dining room. The sliding door leads out to front of facility. A Type A deficiency is being cited today per Title 22 Section 87307(d)(6) wherein the sliding door track in the dining room which leads to the front of the facility was obstructed by a wooden plank which did not allow the sliding door to open freely. Page 2 of 3. 5 residents records were reviewed. 5 out of 5 resident records observed complete and up-to-date. ADM states the needs and services plans are verbally reviewed with the resident and families however the new forms that were developed are not being signed. ADM states a plan to revise the needs and services plan to include a signature portion as acknowledgement that the plan was reviewed and agreed upon. 5 residents centrally stored medications and records were reviewed and no issues were noted. 3 staff files were reviewed and the staff files were complete to include a 1st aid certification, health screening, TB result, personnel record and staff training. Emergency drills are completed quarterly and the last drill was completed on 09/07/2025. Documents were requested to update the facility file to include by 09/24/2025: Lease agreement, LIC308, liability insurance, LIC500, administrator certificates, and surety bond (if applicable). Licensee was informed that the annual licensing fee has not been paid as of 09/17/2025. Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with ADM Lisa Lanford and a copy of the report and appeal rights was provided. Page 3 of 3.the state’s words, verbatim · CDSS document, Sep 17, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Incident visit regarding an elopement that occurred on 8/20/2025. LPA met with Resident Care Supervisor (RCS) Lisa Lanford and stated the purpose of the visit. On 8/21/2025 RCS called the Department and spoke with LPA Christine Kabariti to report the elopement of Resident R1 on 8/20/2025. RCS stated R1 was located outside of the facility on 8/20/2025. RCS stated R1 returned back to the facility that same day and did not sustain injuries during this incident. RCS stated the facility has not submitted an LIC624 Unusual Incident Report/Injury Report and the SOC341 to the Department as of 8/25/2025. LPA requested RCS to submit the LIC624 and SOC341 to the Department on or before 8/27/2025. LPA interviewed 3 staff and toured 1 resident room. LPA requested pertinent documentation to include but not limited to physician's reports, service plans, and resident emergency contacts. LPA determined this case management needs further investigation. No deficiencies cited during today's visit. An exit interview was conducted with RCS Lisa Lanford and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 25, 2025

Allegation investigated: Staff are physically abusing resident while in care Staff are not serving resident food quantity necessary to meet their nutritional needs Staff not ensuring that incontinent residents are kept clean and dry Facility staff are not competent to provide the services necessary to meet the residents need Facility is not administering medication per doctor's order

On 05/07/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the allegations received. LPA met with Medtech Rachel Pearce and explained the purpose of today's visit. Administrator is not present on this day. During the investigation, LPAs conducted interviews, collected and reviewed pertinent documents, and made observations. As a result of the investigation, LPAs could not prove or disporve these allegations took place. Documentation, observations, and interviews are contrary to what the allegations state. These allegations are unsubstantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 7, 2025 · control 26-AS-20241001103255

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Marcella Tarin and Christine Dolores conducted a required unannounced 1 year visit and met with Resident Care Supervisor (RCS), Lisa Lanford. During the visit LPAs toured the facility inside and out. LPAs toured the kitchen area. LPAs observed a perishable food supply of at least 2 days and a nonperishable food supply of 7 days. Refrigerator temperatures maintained at 35 degrees F. Freezer temperature maintained at -6 degrees F. LPAs toured the resident dining area. LPAs observed a wooden plank in the track of the sliding glass door obstructing the sliding glass door in the dining room. Sliding door leads out to front of facility. Licensee was advised to ensure all exit passageways are free and clear of obstruction. Licensee was advised to remove wooden plank in the track of the sliding glass door due to fire safety hazard. LPAs toured 6 resident rooms. LPAs observed 5 resident rooms (Rooms 1, 2, 3, 4, 5) to have half-bed rails. LPAs observed Rooms 1, 2, 4 and 5 had half-bed rails, and Room 2 had full bed rails. RCS obtained orders for 3 resident's half-rails. LPAs observed the physician's order for the full-bed rails. LPAs recorded bathroom water temperature 120 degrees F in all resident bathrooms. LPAs observed all resident bathrooms had functioning lights and available soap and paper towels. LPAs observed each resident room had available bedding and clothing storage areas. LPAs tested the carbon monoxide detector to be functioning properly. The fire extinguisher last serviced on 7/26/2024. LPAs reviewed 5 resident Centrally Stored Medication and Destruction Record (CSMDR). 5 out of 5 reviewed CSMDR were complete during visit. LPAs reviewed 5 out of 5 resident records to be complete. LPAs were unable to review fire drill logs. RCS states she believes the emergency drills are locked in the office, which RCS is unable to access. See LIC809C. LPAs observed 2 out of 5 staff files are missing health screening and TB result. RCS states files may be locked in the front office which RCS is unable to access. LPAs advised that all personnel files should be available to Licensing agency for reviewing. LPAs were unable to review the administrators file. RCS states the file is locked in the front office, which RCS is unable to access. 5 out of 5 staff obtained fingerprint clearance. 1 out 5 staff have First Aid certification. Annual staff training records were reviewed. Documents were requested to update the facility file: liability insurance, administrator certification. Deficiencies were cited per California Code of Regulations Title 22 see LIC809D. This report was reviewed with RCS Lisa Lanford and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 5, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – deficiencies visit. LPA met with Resident Care Supervisor, Lisa Lanford. During visit, the facility had 4 staff members working who are all fingerprint cleared and associated to the facility. On 09/29/2023, the Department received two letters from the facility requesting a Criminal Record Exemption for staff (S1) and (S2). Licensing Program Manager (LPM) Romeo Manzano called and spoke with staff (S3) who states S1 had started working in the facility on-call for the past 6 months. The review of records shows S1’s criminal background clearance was pending, therefore, S1 was not fingerprint cleared to be working facilities. Based on interview, S1 is no longer employed at the facility. S3 states, S1 was hired in February 2023 and worked at least once to twice a week. On 09/29/2023, S1 was immediately released from work for not obtaining a fingerprint clearance from the Department. LPA obtained S1's Guardian information, hire date, and facility's LIC500 via email from S3. A deficiency was cited per California Code of Regulations, Title 22. See LIC 809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500), for staff (S1) working at the facility without fingerprint clearance. Please see LIC-421BG. This report was reviewed with Resident Care Supervisor, Lisa Lanford and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 12, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Oct 13, 2023

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or ... This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not ensure staff (S1) received a fingerprint clearance from the Department pior to starting work which poses an immediate health, safety, and personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: Licensee immediately released S1 from work. Licensee will review section 87355 and submit a statement of understanding to LPA Dolores via email by POC due date.