Purisima Hills

Allegation investigated: Licensee is denying resident access to visitors

Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit to the facility above. LPA met with staff whom called Administrator Susan Marsh and LPA explained the purpose of the visit. Administrator came shortly after to met with LPA. LPA De Leon toured Resident 1's (R1) room and spoke with R1. R1 is on Hospice Services with Dignity. LPA took copies of sign in sheet at the facility for visititation of residnets in care. R1 has had visitors on a regular bases. On 07/02/2026 3 vistors came to the facility to see R1, a volunteer, a shower aide and a registered nurse (RN) all from Dignity Hospice. R1 had a prior hospice volunteer that transferred R1 without a care staff and R1 sustained a skin tear and bruise, the facility asked dignity managmeent not to sent the volutneer due to this incidnet and asked for someone else to be sent in place, another volunteer was sent and has visited R1 on 06/29/2026 and 07/03/2026, the volunteer did not sign in on either visit. Continued 9099-C Unsubstantiated LPA verified with Dignity Hospice that this was a volunteer sent by the agency to visit R1. The facility has a visiting policy of 10am-7pm 7 days per week and when a resident is on hospice services the volunteers can come during and out of those hours if needed. The facility, R1 and Dignity have a hospice care plan for R1 and agree to carry out the care plan and allow for visitation with R1. Staff interviews revealed no visitor for R1 was denied entry to see R1. Based on the lack of evidence this allegation is Unsubstantiated at this time. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Jul 3, 2026 · control 29-AS-20260702133236

Allegation investigated: Facility is not meeting resident's diabetic needs. Facility did not follow physician's orders.

At 5:10am on 05/21/2026, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to continue the investigation to the allegations to this complaint. LPA met with Care Staff 2 (S2) announce who he is and the reason for the visit. LPA texted the Administrator Susan Marsh and informed her of LPA arrival to the facility. LPA conducted observations of Residents morning routines, including, waking, clothes preparation, breakfast, and medication administration.LPA also conducted interview with Resident (R1) and Staff (S2). LPA collected enough evidence to determine and delever final findings as flollows: As to the allegation of, “Facility is not meeting resident’s diabetic needs.” It was alleged that, facility is not following diabetic diet and diabetic care. It was discovered on 05/21/2026 LPA Jeffries conducted a facility continuing investigation visit at 5:10am and observed R1 morning preparation. LPA observed Staff 1 (S1) assisting residents with basic morning routines, including but not limited to dressing, grooming, hygiene, medication administration, breakfast and transportation transfer to day program. CONTINUED on LIC9099-C Unsubstantiated On 05/21/2026, LPA conducted an in-person interview with S2. S2 stated that R1’s blood glucose level was read by S2 at 5:00am via auto read monitor from arm sensor. S2 stated that they adjusted the auto injector to the appropriate level, alcohol swabbed R1s injection spot and R1 self administered insulin using self-injection pen. On 05/21/2026, LPA conducted an in-person interview with R1. When R1 was asked if they had taken their insulin this morning, R1 replied “Yes”, when asked if R1 self injects their own insulin, R1 replied “Yes I do.” When asked if R1 has any problems with injecting their own insulin, R1 stated, “No, I don’t.” LPA noted that R1 was able to answer basic questions with no hesitation or confusion. On 05/21/2026, LPA observed residents’ breakfast to be a protein based meal of eggs and beans. On 05/21/2026, LPA reviewed an updated LIC602 (Physicians Report) singed and dated 05/12/2026, stating Ri is able to administer own injections (with assistance and supervision), and able to perform own glucose testing (with assistance and supervision). LPA collected documentation of weekly meal consumption for R1 showing a protein based diet. Based on interviews, documentation and observation there is not enough evidence at this time to support the allegation of, “Facility is not meeting resident’s diabetic needs.” and is unsubstantiated at this time. As to the allegation of, “Facility did not follow physician’s orders.” It was alleged that Administrator, “took it upon herself” to discontinued Resident 1’s (R1) AM medication. It was discovered on 05/11/2026 by Licensing Program Analyst (LPA) Jeffries, through a medication audit, and medication documentation review and interviews, that on 05/11/2026 a review of R1’s Centrally Stored Medication Record (CSMR) showed that R1’s medication was discontinued on 01/14/2026; a review of R1’s Medication Administration Record (MAR) showed that last time R1 had taken that medication was in the AM of 01/14/2026; on 05/14/2026 LPA received and reviewed NEW PRESCRIPTION SUMMARY from Life Tree Pharmacy, dated 01/15/2026, showing “d/c (medication A). Start (medication B) 01/15/2026” per Physician’s prescription. On 05/11/2026, LPA Jeffries conducted an in-person interview with Administrator, Susan Marsh who stated that R1’s medication was changed by R1’s physician and the prescription was sent to the pharmacy by the physician. Administrator denies personally changing R1’s medications without physician consultation, prescription and discontinuance of any of R1’s medications. At this time there is not sufficient evidence to support the allegation of, “Facility did not follow physician’s orders.” and is unsubstantiated at this time. Exit interview, report read and report provided.the state’s words, verbatim · CDSS document, May 21, 2026 · control 29-AS-20260506124722

Allegation investigated: Staff engaged in an inappropriate conversation with resident in care. Staff does not ensure facility is maintained in good repair. Staff does not follow dietary plan for resident in care. Staff does not ensure food portions are of adequate serving sizes. Staff does not ensure residents transportation needs are being met. Staff does not ensure medications are dispensed as prescribed. Staff does not ensure residents health care needs are being met.

At 8:30am on 01/08/2026. Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to issue final findings to the allegations to this complaint. LPA also conducted facility annual inspection on a separate report on this visit. LPA met with Administrator Susan Marsh who provided verbal permission for Care Staff Elena Perez to sign for both complaint and annual inspection as Administrator had appointments. As to the allegation of, “Staff engaged in an inappropriate conversation with resident in care.” It was alleged that, administrator asked Resident 1(R1) to marry her a year and a half ago, from the date of this report. It was discovered in interviews on 10/30/2025 LPA conducted an in-person interview with R1 who stated, to the question: Was any marriage or marital arrangement ever discussed with you and the Administrator? “That is the most ridiculous thing I have ever heard.” R1 denied recalling any conversations pertaining to marriage. On 10/30/2025 LPA Jeffries conducted an in-person interview with Administrator Susan Marsh who stated that she had never questioned R1 about marriage or any type of marital arrangements. Based on interviews there is not enough information to support the allegation of, “Staff engaged in an inappropriate conversation with resident in care.” and is unsubstantiated at this time. CONTINUED on LIC9099-C Unsubstantiated As to the allegation of, “Staff does not ensure facility in maintained in good repair.” It was alleged that R1’s room was in disrepair, with unsafe wiring hanging out of the walls. On 10/28/2025 LPA conducted a phone interview with Reporting Party, who stated that the room is unsafe because there are wires coming out of the walls everywhere in that room. On 10/30/2025, LPA Jeffries conducted a physical tour of the facility and R1’s bedroom and observed nine (9) individual charging cables connected to a charging hub on R1’s dresser, the cables were hanging off the dresser. LPA noted no wires or unsafe issues on the walls or in the room in its entirety. On 10/30/2025 LPA Jeffries conducted an interview with R1 who stated that all the charging cables are (R1’s) charging cables and needs them placed the way that they are so (R1) can manage to charge (R1’s) cell phone and other devices. On 10/30/2025 LPA Jeffries conducted an in-person interview with Staff 1 (S1). S1 stated that R1 tells staff not to touch R1’s belongings. S1 stated that they have attempted to clean R1’s room and R1 refuses to allow staff to touch anything in R1’s room. On 10/30/2025, LPA Jeffries conducted an in-person interview with facility Administrator, Susan Marsh, who stated that, “R1 yells at us (Staff) when they asked to clean up in R1’s rooms. Administrator stated that R1 has trust issues. Based on complaint narrative and intake interview, LPA observations, and interviews, there is not enough evidence to support the allegation of, “Staff does not ensure facility in maintained in good repair.” and is unsubstantiated at this time. As to the allegations of, “Staff does not follow dietary plan for resident in care.” and “Staff does not ensure food portions are of adequate serving sizes.” It was alleged that R1 is a vegetarian and the administrator is not following R1’s dietary plan which has resulted in R1 losing a lot of weight over the last few months. On 10/30/2025 LPA Jeffries conducted an interview with R1 who stated, “I don’t like the food she (Administrator) buys so I buy my own.” “She (Administrator) will buy vegetarian items, but I like certain things that I buy myself.” On 10/30/2025, LPA Jeffries conducted an in-person interview with S1, S1 stated that they offer R1 a vegetarian diet. LPA observed S1 cutting vegetables and making vegetarian stew/soup. On 10/20/2025 LPA Jeffries conducted an in-person interview with Administrator who stated that the facility provided a vegetarian menu for R1 and provided examples items from the pantry and refrigerator. Administrator stated that R1 likes to buy specialty food items. Administrator stated that the serving portions are up to the residents and how much they want. On 10/30/2025, LPA conducted an in-person interview with Resident 2 (R2) R2 stated that they have no issues with food or portion sizes at this facility. On 10/30/2025, LPA Jeffries observed fruits, vegetables, and other frozen vegetarian labeled foods on hand at the facility. Based on interviews, and observations there is not enough evidence to support the allegations of, “Staff does not follow dietary plan for resident in care.” and “Staff does not ensure food portions are of adequate serving sizes.” and both are unsubstantiated at this time. CONTINUED on LIC9099-C As to the allegations of, “Staff does not ensure residents transportation needs are being met.” and “Staff does not ensure residents health care needs are being met.” It was alleged that the administrator will not provide assistance in arranging transportation for R1’s doctor’s appointments. On 10/30/2025, LPA Jeffries conducted an in-person interview with R1, who stated that, “I haven’t missed any doctors’ appointments, I have a friend who takes me when and where I need to go.” R1 also stated, “I would rather have my friend take me to my doctors’ appointments. I suppose (Administrator) could take me, but I don’t need her because I have my own ride.” On 10/30/2025 LPA Jeffries conducted an in-person interview with Administrator who stated that R1 has a Friend from the community (F1) take R1 out in the community most days. Administrator stated that she has taken R1 to appointments before and the facility will take residents to their appointments as they are needed. On 12/04/2025, LPA observed F1 pick up R1 for a community outing. Based on interviews, admission, and observations, there is not enough evidence at this time to support the allegations of, “Staff does not ensure residents transportation needs are being met.” and “Staff does not ensure residents health care needs are being met.” and is unsubstantiated at this time. As to the allegation of, “Staff does not ensure medications are dispensed as prescribed.” It was alleged that R1 gets nose bleeds and administrator will not provide any assistance with medication to help stop the nose bleeds and the administrator won't dispense the medication. On 10/30/2025 LPA Jeffries conducted an in-person interview with R1 who stated, “I don’t have any problems with taking any of my medications, I just didn’t get it the other night.” On 10/30/2025 LPA Jeffries conducted a medication audit of R1’s medication, centrally stored medication record and medication administration record. LPA noted that medications are noted as being dispensed as prescribed and medication count is correct on 10/20/2025. LPA conducted an interview with S1 who stated that, a few days ago (unsure of what day, about 3 days estimate) R1 had requested help with a nosebleed during the early morning. S1 was assisting another resident and it took approximately 10 to 15 minutes after R1 had requested the medication in question. On 12/04/2025 LPA Jeffries conducted an additional medication audit and found no issues with medication administration, centrally stored medication records and pill count, with no issues. Based on interviews, admission, medication audit and documentation there is not enough evidence at this time to support the allegation of, “Staff does not ensure medications are dispensed as prescribed.” and is unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Jan 8, 2026 · control 29-AS-20251022120849

Type of visit: Required - 1 Year

At 8:30am on 01/08/2026. Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to conduct the facility annual inspection. LPA also issued final findings on a separate complaint report on this visit. LPA met with Administrator Susan Marsh who provided verbal permission for Care Staff Elena Perez (S1) to sign for both complaint and annual inspection as Administrator had appointments. LPA toured facility with facility staff. The facility has 4 single occupancy and 1 double occupancy bedrooms and 3 bathrooms. LPA noted backyard and front yard both had chairs, tables and shade for resident activities and visitations. LPA noted two smoke detectors functioning and working properly where located at each end of the hallway. Fire extinguisher is located in the kitchen and is fully charged and serviced. Inside and outside passageways are free from obstruction. There are no bodies of water on the facility property. The facility temperature was 73 degrees F. Water temperatures were noted to be within 105-120* (f). Residents’ rooms are appropriately furnished with adequate lighting. LPA observed more than two days of perishable and more than seven days of non-perishable food. An Emergency and Disaster Plan and Personal Rights are available and located on the facility kitchen wall. LPA observed Administrator Certificate to be current. Resident and Staff files reviewed. LPA's reviewed Emergency Disaster Plan and Infection Control Plan. LPA reviewed Centrally Stored Medications Records. LPA noted that at this time there were no issues with record reviews. LPA noted that the carbon monoxide detector was not functioning at the time of annual inspection due to dead batteries and a citation was issued.. LPA noted that Administrator ordered a plug-in carbon monoxide detector for replacement during annual inspection. LPA conducted a full review of annual care tools with S1 and Administrator. Exit interview, report read, citation issued appeal rights and report provided.the state’s words, verbatim · CDSS document, Jan 8, 2026

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff mismanaged resident's medication.

At 11:35am on 11/19/2025, Licednsing Program Analyst (LPA) Jeffries arrived to the facility unannounced to address the allegation to this complaint. LPA met with facility Administrator, Susan Marsh, announced who he is and the reason for the visit. LPA conducted a cursory medication audit of medications pertaining to the allegation to this complaint. LPA noted that the Medication Administration Record (MAR) indicated that Resident 1 (R1) MAR November of 2025 entries were noted for the medication in question to the allegation. LPA observed the facility Centrally Stored Medication Record (CSMR) for R1 that noted entry of "18 Pills" and "Plus 50". LPA noted that there were a total of 50 pills counted during medication audit, in addition to the 18 MAR entries equalling the total on the CSMR. At to the allegation of, "Staff mismanaged resident medication." It was alleged that on Novermber 11, 2025 facility only had 9 of 50 pills of medication noted in allegation. On 11/18/2025,Family Member 1 (F1) emailed LPA photographs of medication in question during the initial transfer between F1 and facility staff. CONTINUED on LIC9099-C Unsubstantiated *AMENDED* LPA noted that the pharmacy receipt photographed by F1 noted two boxes of medication in question at a quantity of 50 pills per each box. At the top of the photo there was a highlighted note "1 box qty.50-to (Administrator)" and "1 box qty.50- (F1) Kept" On 11/18/2025 LPA conducted a phone interview with F1 who stated that they provided the facility with one box of 50 and kept one box of 50 of the medication in question; as noted on the photograph provided by F1. On 11/19/2025 LPA Jeffries conducted a cursory medication audit of medication in question to the allegation to this complaint. LPA Jeffries noted that the Medication Administration Record (MAR) Resident 1 (R1) for November 2025; MAR shows 18 entries were noted for the medication in question to the allegation. LPA observed the facility Centrally Stored Medication Record (CSMR) for R1 that noted entry of "18 Pills" and "Plus 50" were entered into the CSMR. LPA noted that there were a total of 50 pills counted during medication audit, in addition to the 18 MAR entries equalling the total on the CSMR, showing that the correct pill count for the medication in question was noted from MAR, CSMR and physical medication audit by LPA. Based on interview with F1, MAR, CSMR, and physical medication audit by LPA there is not enough evidence to support the allegation of "Staff mismanaged resident's medication." and is unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 29-AS-20251114154010

Allegation investigated: Licensee did not issue a refund of advance fees as required.

At 2:40pm on 05/19/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to issue final findings to the allegations to this complaint. LPA also conducted a continuation annual review of facility owned and operated by same Administrator next door under a different license number. LPA met with Administrator, Susan Marsh, announce who he is and the reason for the visit. As to the allegation, “Licensee did not issue a refund of advance fees as required.” It was alleged that facility did not refund deposit of $1250.00 after potential resident was denied admission to the facility. It was discovered that on 05/05/2025, LPA Jeffries conducted an interview with Administrator, Susan Marsh, who stated that they believed that the perspective resident (R1) was being “dumped” by family member (W1) due to W1 flying out of the country the day R1 was negotiated to become a resident at the facility. Administrator stated that W1 did not complete the Admissions Agreement on 04/26/2025 due to lack of power or attorney or conservatorship and R1 was not present at the Admissions Agreement attempted signing. CONTINUED on LIC9099-C Substantiated Administrator stated that R1 and W1 arrived unannounced to the facility on the next day (04/27/2025) without a signed Admission Agreement. At which time Administrator told W1 and R1 that they would not be accepting R1 as a new resident in this facility. On 05/02/2025, LPA Jeffries conducted a phone interview with W1, who stated that they provided Administrator with a check for $1250.00 on 03/31/2025, which was cashed on 04/09/2025. W1 stated that on 04/26/2025 they (W1) were at the facility to sign the admission agreement, however, Administrator would not allow W1 sign without R1 present, and the Admission Agreement did not get signed. W1 stated that on 04/27/2025 they arrived at the facility with R1 and Administrator refused them admission. W1 stated that Administrator only spent 5 minutes talking about photography with R1 and did not do any preadmission's assessment with R1 at any time. W1 stated that the facility has not provided them with any amount of refund. W1 did state that they lost “thousand of dollars” as they had to cancel their flight to Europe due to the refusal of admissions to the facility. LPA observed a handwritten receipt for $1250.00 with memo of, “03/04/2025 to the end of March”. LPA also observed LIC602 Physicians report. LPA conducted a second phone interview on 05/13/2025 with W1 who stated that they still have not received any amount of refund. On 05/19/2025 at 11:49am LPA Jeffries contacted W1 a third time and stated that there had no check issued for any amount. Based on interviews and admission of both Administrator and W1, there is enough evidence to support the allegation of, “Licensee did not issue a refund of advance fees as required.” and is substantiated at this time. Exit interview, report read, citation and appeal rights provide.the state’s words, verbatim · CDSS document, May 19, 2025 · control 29-AS-20250429162031

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(5)(E)1.a.&b. · Plan of correction due date: Jun 2, 2025

87507(5) Refund conditions. (E)Pre- admission fees shall be refunded according to the following conditions:1. A 100 percent refund of a preadmission fee shall be provided to an applicant or the applicant’s representative if: a.The applicant decides not to enter the facility prior to the facility completing a preadmission appraisal as defined in Section 87457. b. The licensee fails to provide full written disclosure of preadmission fee charges and refund conditions. This regulation was not met by lack of evidence of 100% refund. Which poses a danger to Residents in care.the state’s words, verbatim · CDSS document, May 19, 2025

Plan of correction: Administrator will refund 100% of the deposit to W1 on or before 06/02/2025.Administrator will contact LPA by cell phone, email or fax when depot check has cleared their bank account.

Type of visit: Required - 1 Year

At 09:20am on 02/24/2025, Licensing Program Analysts (LPA) Mark Jeffries and Garrett Haner-Tomasko arrived at the facility to conduct an unannounced annual inspection. LPAs met with Licensee Susan Marsh. Announced who they are and the reason for the visit being the facility annual inspection. LPAs toured facility with Licensee. The facility has 3 single occupancy and 1 double occupancy bedrooms and 3 bathrooms. The facility is maintained in conformance with state fire marshal regulations. Smoke detectors are functioning throughout the facility. Fire extinguisher is fully charged and serviced this month. Inside and outside passageways are free from obstruction. There are no bodies of water on the facility property. The facility temperature was 71 degrees F. Water temperatures were noted to be within 105-120 (f). Residents’ rooms are appropriately furnished with adequate lighting. LPA observed more than two days of perishable and more than seven days of non-perishable food. An Emergency and Disaster Plan and Personal Rights are available and located on the facility kitchen wall. Staff files reviewed. LPA's reviewed Emergency Disaster Plan and Infection Control Plan. LPA reviewed medications. Medications are stored in a locked cabinet in the dining room and refrigerator locked in the bedroom closet. During tour of the facility the carbon monoxide detector was noted to be non-functioning, the bath/shower in the hallway bathroom was non-functioning with the water outlet to the tub plugged, and nails were noted to be sticking out of the outside ramp on the west side of the facility, While observing food in the kitchen refrigerator moldy vegetables and an uncovered bowel of cauliflower were cited on the annual care tool. Exit interview, report read, citations issues, appeal rights report provided..the state’s words, verbatim · CDSS document, Feb 24, 2025

The state marks this report as 9 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff failed to provide proper care and supervision for resident Staff did not seek medical attention for resident Staff violated residents visitation rights Facility failed to update responsible party on resident's status

On 9/23/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint investigation visit to the facility above to deliver final findings for the above allegations. During today’s visit, LPA Phillips met with Administrator Sue Marsh and explained the reason for the visit. On the allegation: Staff failed to provide proper care and supervision for resident. It is alleged that on 10/07/2022, Resident #1 (R1) had eloped from the facility without staff supervision and without the use of a wheelchair. The responsible party for R1 indicated that R1 always needs the use of a wheelchair when outside of the facility. Additionally, it is alleged that on 09/09/2023, R1 eloped from the facility without staff knowledge and without the use of a wheelchair. R1 fell during this elopement causing head, arm, and hand trauma which bled profusely. A neighbor of the facility found R1, contacted 911, and returned R1 to the facility as staff allegedly would not leave the facility to aid. Allegedly staff lied to the responsible party of R1 about the distance R1 eloped on 09/09/2023. Continued on 9099-C Substantiated According to the allegation R1 had a fall in the facility in early 2022 and staff were unable to pick R1 up. The staff had to allegedly get another resident out of bed to help pick up R1 off the floor. Allegedly staff allowed R1 to wander freely in the facility while staff sat in another room, even when R1 was the only resident in the facility while other residents attended day program off site. On 11/28/2023, Licensing Program Analyst (LPA) conducted an initial complaint investigation visit to the facility above. During this visit, LPA requested and received relevant facility documentation pertinent to the allegation above for record review. LPA received R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) signed and dated 03/01/2022. Under R1’s Mental Condition it is documented that R1 does not have wandering behavior, does not have confused/disoriented behavior, and is able to leave the facility unassisted. Under R1’s Physical Health Status it is noted that R1 has visual impairment, auditory impairment, but does not have motor impairment/paralysis. Under R1’s capacity for self-care it is noted that R1 needs facility staff stand by assistance with transfers to/from the bath. The ambulatory status of R1 states that they can transfer to and from bed but need staff supervision for stand by assistance. The admission agreement to the facility for R1 signed and dated on 02/24/2022 indicates that R1 will receive assistance with personal activities of daily living including mobility tasks. The documented resident appraisal for R1 while in care indicates that R1 has physical disabilities including needing staff assistance to stand and vision loss/degenerative blindness. The resident appraisal of R1 indicates the functional capabilities of R1 as frail or slow, difficulty climbing or descending stairs, requirement of grab bars in bathroom, and that R1 uses a wheelchair. R1 had a facility documented fall in care on 10/09/2022, and on 10/22/2022 a documented hospital referral for R1 Physical Therapy indicated that R1 was referred to evaluate and treat frequent falls as well as unsteady gait from 10/18/2022 through 10/18/2023. The Appraisal/Needs and Services (ANS) Plans for R1 dated 04/01/2022 and 11/10/2022 document under R1’s physical health that they use a wheelchair and/or walker within the facility but have a mandatory wheelchair for the outdoor areas of the facility and on excursions. The persons responsible for implementation are indicated as all staff in the facility. Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated. Continued on 9099-C On the allegation: Staff did not seek medical attention for resident. It is alleged that when the responsible party for R1 did not visit the facility for long periods of time, they would return to the facility to find R1 picking at their face with dried blood on their face and neck which staff attempted to cover with band aids. According to the allegation, staff stated that the incident had occurred due to R1’s mental state but failed to provide care for mental health issues. On 11/28/2023, LPA was provided with narrative charting for a Record of Medical and Dental Care of R1 during the year of 2022. On 11/02/2022, R1 was sitting outside facility on the front porch area waiting for their responsible party to come and pick them up. When the responsible party for R1 arrived, they found R1 unresponsive. The responsible party had to alert the administrator in the facility to come and observe. Staff informed the responsible party of R1 that they had just had contact with R1, and informed responsible party of R1 that R1 was napping on the porch of the facility. However, when paramedics arrived after responsible party called 911, they determined R1 had very low blood pressure and irregular heartbeat. R1 was admitted to the hospital. LPA received documented hospital discharge paperwork for R1 from 11/02/2022 after the unresponsive incident regarding R1 on 11/02/2022. R1 was admitted for observation, low blood pressure, and arrhythmia. Additionally, LPA received a record of medical and dental visits for the facility from 02/20/2023 regarding the first aid care attempted by the facility on the scratches on R1’s face. There is no evidence the primary care physician of R1 requested mental health services for R1. LPA received R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) signed and dated 03/01/2022. There is no documented need for mental health services for R1 in the Physician’s Report. However, the facility did not seek medical attention for R1 regarding the incident on 11/02/2022 and the incident on 10/07/2022. Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated. On the allegation: Staff violated resident’s visitation rights. It is alleged that the administrator informed a visitor to the facility that they had the right to deny visitation to family members. LPA confirmed a credible witness acknowledged that the administrator was informed that R1 and all residents in care at the facility have a right to visitations by their family members and others in general. The credible witness determined that R1 wanted to be visited and participate in outings from the facility with visitors. Continued on 9099-C The admission agreement to the facility for R1 signed and dated on 02/24/2022 indicates that the agreement must include the facility policy concerning family visits and communication. The policy must be designed to encourage regular family involvement with the resident. The policy must also provide ample opportunity for family participation in family activities. The documented facility visiting hours for general visitation is 10:00am-3:00pm daily. Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated. On the allegation: Facility failed to update responsible party on resident's status. On 11/02/2022, R1 was allegedly found unresponsive on the front deck of the facility. Paramedics arrived and determined R1 had very low blood pressure and irregular heartbeat. R1 was admitted to the hospital, but staff informed the responsible party of R1 that they were just napping on the porch of the facility. Allegedly staff failed to inform the responsible party of R1 about the extent of the elopement of R1 on 09/09/2023 and the medical treatment required. On 11/02/2022, R1 was sitting outside facility on the front porch area waiting for their responsible party to come and pick them up. When the responsible party for R1 arrived, they found R1 unresponsive. The responsible party had to alert the administrator in the facility to come and observe. Staff informed the responsible party of R1 that they had just had contact with R1, and informed responsible party of R1 that R1 was napping on the porch of the facility. However, when paramedics arrived after responsible party called 911, they determined R1 had very low blood pressure and irregular heartbeat. R1 was admitted to the hospital. Licensee failed to report to Licensing the elopements by R1 10/07/2022 and on 09/09/2023. Additionally, Licensee failed to report to Licensing the falls by R1 on 08/24/2022 and 10/09/2022. On 11/28/2023, Licensing Program Analyst (LPA) conducted an initial complaint investigation visit to the facility above. During this visit, LPA requested and received relevant facility documentation pertinent to the allegation above for record review. LPA received an Unusual Incident/Injury Report (UIR) handwritten by the facility administrator for the fall incident by R1 on 10/09/2022, but this UIR was never submitted nor received by Licensing at the time of the incident. Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated. Exit interview conducted. Copy of report provided to facility. LPA conducted physical site visits to the facility on 11/28/2023, 02/23/2024, and 09/23/2024 including an annual facility site inspection. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. LPA inspected and observed the front outdoor area of the facility, which consists of cement walkways and grass areas. The facility outdoor front yard area is paved with a walkway up to the front door of the facility. The front yard has a patio with shade and outdoor furniture conducive for outdoor visitation. During all visits by LPA, there were no observed front deck ramp and railing safety hazards which would cause immediate or potential harm to residents in care at the facility. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated. On the allegation: Staff spoke inappropriately to residents. It is alleged that the administrator of the facility has verbally abused facility staff members causing them to quit employment. It is also alleged that the facility administrator yelled at visitors to the facility in front of residents, which caused emotional distress to residents. Additionally, it is alleged that the facility administrator makes derogatory statements to visitors. Administrator was reminded by LPA to minimize negative/derogatory statements to staff and/or visitors to the facility. The admission agreement to the facility for R1 signed and dated on 02/24/2022 indicates that the licensee must advise the resident or responsible person of, and provide a copy of, the resident’s personal rights specified by law. The advisement of personal rights and signed copy of personal rights are initialed by R1’s responsible party. According to the allegation, staff did not speak inappropriately to residents, but to visitors and other staff members. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated. On the allegation: Staff do not provide residents with adequate food service. It is alleged that R1 complained often about the poor quality of the food in the facility. Because of R1’s alleged complaints about the food, R1 was brought food to the facility by visitors on numerous occasions. On 02/23/2024, the LPA conducted an annual facility site inspection of the facility above. Contd. on 9099-C LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The LPA inspected the kitchen/food service area and observed that perishable food items were in good condition, with proper expiration dates precluding the perishable items from expiring. The facility had a sufficient supply of perishable and non-perishable food, which would last over a week (7 days). The freezer and refrigerator were both the appropriate temperate Fahrenheit for the storage of food and prevention of spoiling. There was emergency food and water in the garage of the facility and in the extra perishable food storage area which was observed to be in good condition. Kitchen appliances were in operable condition and looked clean/in good repair. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. LPA also visited the facility above for complaint investigation visits on 11/28/2023 and 09/20/2024. During these complaint investigation visits, LPA did not observe any food of poor quality i.e. spoiled/rotten/expired within the facility. Additionally, LPA did not observe any appliances or kitchenware in disrepair that would lead to inadequate food service. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated. On the allegation: Staff did not safeguard residents' belongings. It is alleged that staff told R1 not to bring personal food items to the facility because staff see Resident #2 (R2) taking R1’s belongings on a consistent basis. Allegedly R1 ordered and paid for 2 large pizzas, but only got one piece before the entire pizza was taken. On 02/23/2024, the LPA conducted an annual facility site inspection of the facility above. During this annual inspection, LPA interviewed both Staff and residents in care. LPA additionally conducted on-site facility observations on 11/28/2023 and 09/20/2024. During all visits to the facility by LPA and concurrent interviews with Staff and residents, no statement was made by either any Staff or any resident that resident belongings are not safeguarded in the facility. LPA did not physically observe any resident belongings not being safeguarded by Staff in the facility during visits on 11/28/2023, 02/23/2024, or 09/20/2024. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated. Continued on 9099-C On the allegation: Staff mismanaged residents' medications. It is alleged that the facility administrator ordered the responsible party of R1 to order more medications for R1 as R1 was out. The responsible party of R1 provided the date the prescription was to be filled and noted it was too early. The staff eventually found R1’s extra medication in an overflow bag. Allegedly staff at the facility administered medications to R1 that were not prescribed by a physician and withheld medications that were prescribed by a physician. Staff allegedly argued medications for R1 were not needed even though they were prescribed by the primary physician of R1. On 11/28/2023, LPA conducted a complaint investigation visit to the facility above. During this visit, LPA requested and received relevant facility documentation pertinent to the allegation that Staff mismanaged residents’ medications for record review. LPA received R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) signed and dated 03/01/2022. Under medication management, the Physician’s Report indicates that R1 is able to administer their own medications, but they need a medication box set up for them to take their medications. Facility documentation received by LPA from August 2023 indicated the outdated/not currently prescribed medications for R1. These medications were prescribed previously for R1 by their primary care physician (PCP) but are not on a current physician report and/or are not currently prescribed by R1’s PCP. The facility documented that these medications were taken out of R1’s medication box as of August 2023. The Medication Administration Record (MAR) for R1 from August 2023 onward indicates that the medication alleged by RP that was being administered to R1 by Staff despite not being prescribed by a physician, was discontinued and there is no documented evidence of R1 being prescribed this medication any further. Based on interview by LPA with Staff on 11/28/2023 and 09/20/2024, there is no evidence that the facility administrator ordered the responsible party of R1 to order more medications for R1 as R1 was out. LPA interviews with Staff additionally did not corroborate that staff eventually found R1’s extra medication in an overflow bag. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated. Exit Interview Conducted. Copy of this report provided to the facility.the state’s words, verbatim · CDSS document, Sep 23, 2024 · control 29-AS-20231127090429

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Sep 24, 2024

Addt'l Personal Rights Residents...(a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, services that meet individual needs…delivered by staff sufficient in numbers, qualifications, competency… This requirement is not met based on records review, licensee did not comply with the section cited above when Resident #1 eloped from facility without staff knowledge, and was not provided medical attention by facility which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 23, 2024

Plan of correction: Licensee will provide all Staff with a training on Resident Personal Rights and incidents/situations requiring Staff to assist residents with medical attention. Evidence of this training will be provided to LPA by 09/24/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Oct 21, 2024

Personal Rights All Residents...(a) Residents in all residential care facilities for the elderly shall have following personal rights: (11) To have visitors…permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement is not met based on interviews/records review, licensee did not comply when a visitor to the facility was informed by Staff that they had the right to deny visitation to family members, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 23, 2024

Plan of correction: Licensee will provide all Staff with a refresher training on the facility visitiation policy as documented on facility resident admission agreement. Evidence will be provided to LPA by 10/21/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Oct 21, 2024

Personal Rights...(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement is not met as evidenced by: Based on interviews and records review, licensee did not comply with section cited above by failing to report an incident and change of condition to a resident’s responsible party, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 23, 2024

Plan of correction: Licensee will provide all Staff with Personal Rights training regarding residents in care at the facility. Training will include personal rights training for all deficiencies cited, including the informing of responsible parties when a resident has a change in condition.

Type of visit: Required - 1 Year

On 02/23/2024, Licensing Program Analyst (LPA) Brian Phillips arrived unannounced for an unscheduled visit to conduct a required Annual site inspection visit at the facility above. When the LPA arrived, they were greeted by Licensee/Administrator Susan Marsh, and informed them of the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This is a Residential Care Facility for the Elderly (RCFE), with an approved fire clearance capacity of Six (6) residents. Of the approved residents in care at the facility, Five (5) may be Non-Ambulatory and One (1) may be Ambulatory. The residents have an age range of sixty (60) years of age and older. The facility has an approved Hospice Waiver for One (1) Resident. The physical plant of the facility consists of a main entrance, kitchen, living room, garage with laundry room area, three (3) resident restrooms, four (4) resident bedrooms, and multiple indoor storage closets. The facility contains an outside area for residents to utilize for outdoor activities/outdoor visitations and an outdoor patio area with furniture and shade. KITCHEN: The facility maintains one (1) main kitchen room/area for the facility. The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in a locked drawer inaccessible to residents in the garage of the facility. Kitchen appliances were in operable condition and looked clean/in good repair. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which would last over a week (7 days). The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation between 105-120 degrees Fahrenheit (111 degrees Fahrenheit). Items that could constitute a danger to residents are kept inaccessible to residents outside of the kitchen area. The kitchen was clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. Continued on 809-C The freezer and refrigerator were both the appropriate temperate Fahrenheit for the storage of food and prevention of spoiling. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. COMMON AREAS: The indoor areas of the facility consists of resident bedrooms, restrooms, shower areas, a Centrally Stored Medication area, kitchen, dining room, storage area closets/rooms, living room, and a central lobby/entrance area upon entry into the facility. At the time of the visit, the common areas of the facility were observed to be appropriately furnished, with all furniture in good condition. There is one (1) fireplace in the facility, which is appropriately screened and inaccessible to residents. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector(s) were operational at the time of the visit. The facility has a fire extinguisher that was fully charged and serviced annually, being tagged as serviced in February 2024. This facility contains a dining room, four (4) resident restrooms, three (3) resident shower/bathing rooms, living room area, kitchen area, laundry room area in the garage, a locked centrally stored medication containment area, extra storage areas for additional perishable food, closets/rooms in the hallways of the facility containing extra linen/bedsheets/pillows, and storage areas for resident personal hygiene equipment constituting the interior areas of the facility. The LPA observed required postings throughout the common spaces including Resident Personal Rights and Contact information for Ombudsman as well as Licensing. There are activity supplies and equipment, including activity materials for the residents such as television, puzzles, games, etc. All window screens were in good repair. There is appropriate lighting in the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all inclines are well-lit with no stairwells/stairs for resident use. The laundry area for the facility is located in the garage of the facility that is inaccessible to residents. There is a main entrance walkway into the facility and an administrative entrance area for visitors. The kitchen, living room, and dining area are neat and clean. The facility maintains a comfortable temperature. Hallways, bedroom doors, and walls are in good repair. OUTSIDE/LAUNDRY/MISCELLANEOUS: The front outdoor area of the facility consists of cement walkways and grass areas. The facility outdoor front yard area is paved with a walkway up to the front door of the facility. The front yard has a patio with shade and outdoor furniture conducive for outdoor visitation. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. The exterior of the facility has a closed perimeter which consists of a fence around the backyard area of the facility. Inside of the perimeter is the outdoor/outside activity area for residents with a patio in the backyard, furniture, shade. Contd. on 809-C The facility has an outdoor activity area that is provided with a shaded area and furnished for outdoor use. There are no bodies of water noted on the facility property. The designated laundry area is in the garage of the facility, which is also the area where locked storage of cleaning products and sharp instruments which could constitute a danger to residents are stored, which are kept locked and inaccessible to residents. Staff members are the only individuals allowed to do laundry and the garage is inaccessible to residents. There was emergency food and water in the garage of the facility and in the extra perishable food storage area which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to residents are kept in areas inaccessible to residents. There is a first aid kit that includes sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. The vehicles used to transport residents are in safe operating condition with appropriate insurance information. LPA did not observe any noticeable outdoor hazards in areas accessible to residents. BEDROOMS: The facility has four (4) resident bedrooms, both individual bedrooms for one (1) resident and shared bedrooms for two (2) residents. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The bedrooms have storage areas for clean linens, towels, pillows, etc. Each resident’s bedroom has a single bed or beds, nightstand, and lights/nightstand lamps to provide sufficient lighting. Each closet in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assistive device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. RESTROOMS: There are three (3) resident restrooms in the facility. The facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms/showers inspected had assistive equipment for residents including grab bars and/or non-skid surfaces. The restrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per the regulations between 105-120 degrees Fahrenheit (108 degrees Fahrenheit). Nightlights are installed in the hallways outside of the resident restrooms. The facility maintains private, personal restrooms as well as a communal restroom for residents in care. All resident restrooms consist of a sink and toilet, while the resident shower/bathing areas consist of a shower and/or bathing area with grab bars and non-skid surfaces. RECORDS: The facility keeps confidential storage of both resident and Staff member records on-site at the facility. Continued on 809-C Staff member records were reviewed for, but not limited to Health Screening Report/Tuberculosis (TB) Clearance for facility personnel, Personnel Record (employment application), verification of age over 18 years old, education, and experience, approved Certification for the Administrator, verification of first aid training, Criminal Record Statement, Criminal Record Clearance/Exemption, Verification of Staff training, Employee Rights, and Abuse Reporting Requirements. All staff members’ personnel records reviewed by LPA had the appropriate documentation. The administrator of the facility has an active Residential Care Facility for the Elderly (RCFE) Administrator Certificate with an effective date of 11/03/2022, and an expiration date of 11/02/2024. Resident records were reviewed for, but not limited to Pre-Admission/Placement appraisals, Resident Appraisals, Appraisal Needs and Services Plan (ANS), Physicians’ Report for RCFE, Identification and Emergency Information, Current Admission Agreement with signatures, Personal Rights for Residents, Record of Residents safeguarded cash resources, Record of Resident personal property/valuables, Physician Orders for Life Sustaining Treatment (POLST), Responsible Person or Conservator of Resident, Self-management of medications if applicable, Medication Orders, and Medication Logs. The facility also keeps records of resident vital signs and a resident weight record for all resident files reviewed. All resident records reviewed by the LPA had the appropriate documentation with no missing or incomplete information. MEDICATIONS: The facility maintains a locked centralized storage area for resident medications. Centrally Stored Medications are in a locked storage containment area within a cabinet in the kitchen area of the facility, which is located in the Main building of the facility. The medication room remains locked at all times, inaccessible/locked to residents. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record, The Medication Administration Record, and the record of Controlled Medications. LPA audited the medications for residents and noticed no irregularities or issues concerning the dispensing of medications or the logging of medications. The medications in the facility were labeled appropriately with no additional or prohibited markings by the facility. INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening and a sanitation station. The staff members will keep up signs that promote good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. Continued on 809-C FACILITY DOCUMENTATION: There are required postings throughout the facility, including emergency exit plans with necessary telephone numbers. The facility keeps posted copies of facility documentation such as the RCFE License Certificate, LIC 500 Personnel Report, Documentation of Facility Waivers, Plan of Operation, Emergency Disaster Plan for Residential Care Facilities for the Elderly (RCFE), Facility Infection Control Plan/Mitigation Plan, Certificate of Liability Insurance, Valid Administrator Certificate, and a Facility Sketch. Provider Information Notices are available and able to be presented to Staff, residents, visitors, and accessible to LPA upon request during the inspection process. No deficiencies cited. Exit interview conducted. A copy of the report was issued to the facility.the state’s words, verbatim · CDSS document, Feb 23, 2024