Rancho Penasquitos Senior Living

Allegation investigated: Staff shook a resident in care. Staff yelled at a resident in care.

Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced phone call to deliver findings regarding the above-mentioned allegations LPA spoke with the Memory Care Director. LPA identified herself and disclosed the purpose of the visit and elements of the findings with the Memory Care Director. On March 15, 2024, the Department received a complaint of allegations made against staff members at formerly known as Pacifica Senior Rancho Penasquitos regarding two specific incidents: Staff shaking a resident in care and Staff yelling at a resident in care. On March 21, 2024, LPA conducted a facility tour and collected resident and personnel records. The Department conducted an investigation into the above allegations. The staff member in question was not identified and, therefore, could not be interviewed. Continued on 9099C Unsubstantiated Staff interviewed stated that they had not heard of the allegations. During interviews, staff reported that Resident 1 (R1) was considered one of the more difficult residents due to behaviors. Records reviewed indicate that R1 resided at the facility from December 4, 2023, through February 29, 2024. Documentation reflects primary diagnoses including Parkinson’s disease and dementia with behavioral disturbances, as well as chronic anxiety. R1 was not available for interview due to no longer residing at the facility at the time the complaint was received. LPA attempted to interview additional residents in the memory care unit; however, residents encountered did not engage or respond to attempts at communication, and interviews could not be conducted. A facility tour was conducted, and no health or safety hazards were observed at the time of the visit. Based on interviews conducted, records reviewed, and observations made, there is insufficient evidence to support the allegations. Therefore, the allegations are deemed unsubstantiated. A finding that is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Memory Care Director. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Memory Care Director via electronic signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Aug 20, 2026 · control 08-AS-20240315143917

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Executive Director Heather Myers to discuss the purpose of the visit. Today's visit is in response to the facility's self report regarding memory care Resident 1 (R1) becoming lost on a hike after being signed out of the facility by a friend. LPA collected records, conducted interviews and health and safety check for R1. Interviews and records revealed that Law enforcement and facility staff arrived on scene to search for R1 and R1's family was notified. R1 was found by law enforcement approximately 3.5 hours after R1 was identified to be missing. R1 was assessed by paramedics and placed on 48 hour alert charting for monitoring. R1 did not suffer any injuries from the incident. The facility consulted R1's family and friend regarding R1 leaving the facility. Training is to be provided to the friend for future visits, including when R1 is signed out of the facility. Additionally, R1 will be provided with a location tracker to monitor their location when away from the facility. Executive Director will provide information regarding the training provided to R1's friend, as well as any updated procedures for when R1 leaves the facility. No health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Executive Director Heather Myers, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Apr 1, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Receptionist Hayley Josten. Executive Director Heather Myers arrived later during the visit. The facility's license shows a maximum capacity of one-hundred-and-twenty non-ambulatory residents, ten (10) of which may be bedridden. Bedrooms 110, 112, 123, 131, 134, and 207 are cleared for bedridden. Additionally, the facility has a hospice waiver for fifteen (15) and the first floor features delayed egress for the memory care unit. During today’s inspection there were seventy-nine (79) residents in care. Note, LPA did step out for lunch from 12:10-1:10pm. LPA and Executive Director Myers toured the interior and exterior of the facility and inspected a sample of occupied and unoccupied resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms inspected contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Sink in 1st floor medication room read at 108.6F, common restroom sink on the 2nd floor read at 105F, and a resident unit sink on the 3rd floor read at 107.7F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. [Continued on LIC 809-C] [Continued from LIC 809] The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Laundry rooms were locked and inaccessible to residents in care. LPA observed physical separation of soiled/clean laundry and an organization system to keep track of whom items belonged to. LPA observed multiple postings of activity calendars throughout floors. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were locked and inaccessible to residents in care. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Executive Director Myers, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months, dated for December 2025. Last emergency drill conducted for staff was held on 1/22/26 for the topic of fire. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed two (2) staff and two (2) clients, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Myers to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jan 29, 2026

Type of visit: POC

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Plan of Correction (POC) visit regarding a deficiency that was cited on December 23rd, 2025. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Receptionist Hayley Josten, Memory Care Director Cristina Coronado, and Executive Director Heather Myers. On 12/23/25 LPA cited a deficiency for not meeting reporting requirement timelines. The POC due date was set for January 5th, 2026. Licensee designated representative sent LPA an email 1/7/26 notifying LPA that POC would be submitted the following day, 1/8/26. Licensee submitted proof of correction to LPA via email on 1/8/26, and POC was cleared. Licensee did not communicate LPA prior to the POC due date for additional time. As the Licensee failed to correct the deficiency and notify LPA by the due date, LPA conducted a POC visit to verify correction and to assess a Civil Penalty Violation for Failure to Correct. A Civil Penalty of $100.00 a day has been assessed from 1/6/26 to 1/8/26 for a total of $300.00. An exit interview was conducted with Executive Director Myers to whom a copy of this report, the POC Clearance letter, the LIC 421FC, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jan 29, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Heather Myers. LPA also met with Business Office Manager Jessica Mallory. Today's visit was in response to three (3) written reports which Licensee self-submitted; all were received at the CCLD San Diego Regional Office on 12/24/2025. The first was an LIC624 Incident Report, describing an altercation between Resident #1 (R1) and Resident #2 (R2) on 12/09/2025, for which R1 was medically cleared at the emergency room. The second was an LIC624 Incident Report, describing R1 having an unwitnessed fall in their bedroom on 12/11/2025, for which R1 required hospitalization. The third was an LIC624A Death Report, which described R1 passing away at the hospital on 12/17/2025. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. During today’s visit, LPA performed a brief facility tour and welfare check on R2 and other residents in care. LPA interviewed facility managers and collected copies of pertinent care records on R1 and R2. Per interview of the facility administrator: Hospital staff reported that R1 was very agitated while at the hospital, requiring physical restraints and new medications, and that R1 had refused to eat food and drink by mouth, from 12/12/2025 until they died on 12/17/2025. LPA also audited the facility’s employee roster against CDSS’ Guadian System. LPA observed, and manager interviews confirmed: One (1) of one-hundred (100) employes, Staff #1 (S1), did not have a Criminal Background Clearance to work, as required. Records showed S1 was a per-diem employee who was hired on 01/10/2025. Per phone interview of S1, they had worked more than five (5) days at the facility since then. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] One (1) deficiency was cited today per California Code of Regulations, Title 22 (see the attached LIC809-D page). Since the violation was regarding a staff background clearance, and immediate civil penalty of $500 was assessed (refer to the LIC421-BG page). A Plan of Correction were jointly formed with the Licensee. An exit interview was conducted with Executive Director Heather Myers, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Dec 26, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87335(e)(2) · Plan of correction due date: Dec 26, 2025

87355 Criminal Record Clearance: (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: (2) Obtain a California clearance or a criminal record exemption as required by the Department…” This requirement was not met, as evidenced by: Based on record review and manager interviews, Licensee did not ensure that 1 of 100 staff (S1) obtained a California clearance or a criminal record exemption as required by the Department, prior to working in the licensed facility. This posed an immediate safety risk to 75 of 75 residents [Resident #1 (R1) through Resident #75 (R75)] in care.the state’s words, verbatim · CDSS document, Dec 26, 2025

Plan of correction: S1 was not on duty today. Licensee agreed to immediately remove S1 from the work schedule and instruct them to complete LiveScan fingerprinting. This resolved the immediate risk. Licensee agreed to keep S1 off-duty until receipt of confirmation of a successful background clearance for S1 from CDSS.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Memory Care Director Cristina Coronado. Executive Director (ED) Heather Myers arrived later during the visit. Community Care Licensing received an Incident Report on 12/22/25 in which it was reported that on 12/9/25, a Resident (identified as R1), fell out of their wheelchair due to uneven concrete when being assisted by a staff member down a ramp at the facility. Per the report, the resident hit their knees and head on the ground. Emergency services were contacted and resident was transported to the hospital where no injuries were found. Per the report, resident returned to the facility with no new orders. R1's responsible party and primary care physician were notified. During today's visit, LPA conducted interviews and file review. Additionally, LPA attempted to conduct a health and safety visit with R1, however R1 was being assisted by staff. LPA attempted again later during the visit, but R1 was attending lunch and LPA did not want to disturb their meal. Due to time constraints, LPA was unable to complete a determination regarding this case management visit, and additional visits may be necessary to complete review of this incident. At this time, LPA observed no health and/or safety concerns and no deficiencies were cited during today's visit. An exit interview was conducted with ED Myers to whom a copy of this report was provided. Their signature below confirms receipt of this document.the state’s words, verbatim · CDSS document, Dec 23, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Memory Care Director Cristina Coronado. Executive Director (ED) Heather Myers arrived later during the visit. Community Care Licensing received an Incident Report on 12/22/25 in which it was reported that on 12/8/25, a Resident (identified as R1), was noticed not to be present by a caregiver around 11:30am. Per the report, multiple staff then searched the facility to find R1, who was found to have fallen down a stairwell with their wheelchair on top of them. R1 was noted to be awake and alert and staff contacted emergency services who then transported R1 to the hospital where they were treated for a large hematoma to their glute area. R1 returned to the facility 12/11/25 with orders for new medications. During today's visit, LPA conducted interviews and file review. Additionally, LPA conducted a health and safety visit with R1. Per staff interviews, a fire alarm had gone off during lunch (from 11am-12pm) and staff began conducting room checks after it had been determined to be a false alarm from the kitchen. Staff interviews corroborated that R1 must've panicked or gotten confused from the alarm and tried to self-evacuate from their room before staff got to them. The stairwell R1 fell in is immediately next to R1's room. Interview with the staff member who first noted R1 to be missing from their room stated that they had assisted R1 with bathing earlier and that R1 was seated in their recliner watching television when the staff member left to assist the next resident with their shower. [Continued on LIC 809-C] [Continued from LIC 809] All staff interviews corroborated that R1 is a fall risk and required assistance when ambulating with their walker or wheelchair. File review of R1's physician's report (dated September 2023) revealed that R1 has a diagnosis of Dementia and utilizes a walker due to motor impairment. Per review of R1's assessment dated June 2025, R1 is noted to ambulate independently with or without an assistive device and noted to be a fall concern. However, per R1's service plan dated December 2023, R1 requires total assist with ambulation. It is noted that R1 is able to ambulate with the assistance of a walker but that an escort will be provided for safety. R1's full service plan was not updated until December 2025, after this incident. Per review of the new service plan, R1 remains a total assist for ambulation and that R1 will be escorted to meals and activities. Goals and interventions to reduce R1's fall risk now include additional reminders to utilize their pendant for assistance and for staff to provide reminders for R1 to utilize their assistive device if observed trying to ambulate without it. Per interview with administrative staff, the facility has also implemented higher frequency checks on R1 (hourly). The facility responded accordingly by conducting room checks after a fire safety event and conducting a search once R1 was noted to be unaccounted for and then arranging for prompt medical attention once found. However, one (1) Type B deficiency is being cited today as the facility failed to submit a written report of the incident to the Department within seven (7) days. Date of incident was 12/8/25, date of report submission was 12/21/25. Details of the deficiency are noted on the attached LIC 809-D along with Plan of Correction (POC). One deficiency was cited during today's visit. An exit interview was conducted with Executive Director Myers to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Dec 23, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jan 5, 2026

87211(a)(1): A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This requirment is not met as evidenced by: Based on file review and interviews, the Licensee did not ensure submission of incident reports to the Department were within the required timeframe, posing a potential health, safety, and personal rights risk to 76 out of 76 residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2025

Plan of correction: Licensee will conduct an in-service review with staff on reporting requirements as outlined in CCR 87211 and submit proof to LPA by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Business Office Manager Kamryn Finchum. Community Care Licensing received an Incident Report on 5/19/25 in which it was reported that Resident #1 (R1) was found unresponsive by care staff while sitting out in the patio area of the facility. Per the report, other residents present at the time stated R1 was out there for about an hour. Emergency services were contacted and R1 was taken to the hospital where they were treated for heat exhaustion. R1's Responsible Party (RP) and Primary Care Physician (PCP) were notified. During today's visit, LPA conducted file review, a health and safety visit with R1, and provided consultation with Business Office Manager Finchum. No Deficiencies were cited during the visit. An exit interview was conducted with Business Office Manager Finchum to whom a copy of this report was provided. Their signature below confirms receipt of this document.the state’s words, verbatim · CDSS document, May 28, 2025

Allegation investigated: Neglect resulting in pressure injuries Staff did not meet resident's incontinence needs Staff did not provide clean linen to resident

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced complaint investigation visit to deliver complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Wes Hebner. Throughout the investigation, the Department secured pertinent records and conducted interviews with external and internal sources, including staff and residnets. It was alleged neglect resulted in pressure injuries. On February 10th, 2023, it was reported to the Department staff were not repositioning Resident # 1 (R1), which led to R1 sustaining pressure injuries. R1, a ninety-four-year-old resident, was admitted to the facility on 01/05/2021. A Physician’s Report (LIC 602) dated January 5th, 2021, revealed R1 was diagnosed with Mild Cognitive Impairment, and was at risk for falls. (See LIC 9099-C for continuation of report.) Substantiated R1’s ambulatory status declined, and R1 became increasingly bed bound. R1 was placed on hospice services on August 26th, 2022. The facility’s Needs and Services plan noted R1 required total assist. A Resident Assessment conducted on February 16th, 2023, revealed R1 required assistance with toileting and incontinence checks and changes. R1 required a two person assist for transfers, ambulating, and escorting. An external source revealed hospice visited R1, and trained caregivers on repositioning, wound care and keeping R1 clean and dry. This was documented on the Hospice care notes obtained from the facility. Interviewed caregivers and medication technicians stated they would reposition R1 every two hours, changed R1’s briefs, kept R1 dry, and would change out soiled bandages per hospice’s and nurses’ directions. These interviews noted hospice had not advised staff of any severe discrepancies in R1’s care, nor provided training. Although facility staff stated they kept R1 dry, repositioned R1, and that hospice did not communicate the severity of R1’s wounds, numerous notes from hospice noted R1 was found with soiled briefs and linens on multiple occasions. The hospice notes also revealed hospice communicated the importance of repositioning R1, and that hospice provided training for staff on multiple visits. Interviews with the facility’s Executive Director and Resident Care Coordinator confirmed the facility did not obtain a hospice care plan for R1, and instead followed the facility’s care plan for R1. The facility’s Need and Service Plan for R1 noted staff would follow orders within staff’s scope of practice. This plan did not note the need for repositioning. Interviews confirmed R1’s wound healing did not progress until after a care conference was held with facility management on February 23rd, 2023, and after the complaint was submitted to the Department. Based on the information provided during the investigation, the allegation was substantiated. It was alleged staff did not meet R1's incontinence needs. It was reported to the Department R1 was found to be soiled on multiple occasions. Hospice notes revealed hospice staff found R1 with soiled briefs and facility staff was trained and advised of the importance of keeping R1 dry. Interviewed staff reported providing R1 incontinence care and keeping R1 dry. Interviews with internal and external sources reported concerns with how long it took staff to respond to calls for assistance with incontinence care. (See additional LIC 9099-C for continuation of report.) Based on the evidence obtained, the allegation was substantiated. It was alleged staff did not provide clean linens to a resident. It was reported to the Department R1 was found with dirty linens on multiple occasions. Interviews with internal sources revealed the residents’ responsible parties and families were responsible for providing linens for each resident. Residents had a minimum of two linen sets, but some had more depending on their needs. During a visit to the facility, the LPA observed some of the residents’ linen supplies and the facility’s own linen supply. The facility had approximately six sets of sheets available, in the event a resident did not have a clean set. Although, the bedrooms observed had enough lines, there were several interviews that revealed there were occasions when linens were dirty and some residents had to wait for a set to be washed, or responsible parties were contacted to provide more lines. There were occasions when residents had to wait until the end of a shift for a clean set of linens to be placed on their bed. Based on the evidence obtained, the allegation was substantiated. These deficiencies were cited in an LIC 9099-D form and Plan of Corrections (POCs) were jointly formulated with Executive Director Wes Hebner. An exit interview was conducted with Executive Director Wes Hebner, to whom a copy of this report, LIC 811 Confidential names list, and Licensee Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Apr 8, 2025 · control 08-AS-20230210103200

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Apr 8, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)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: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidence by: Based on interviews and review of records, the licensee did not ensure R1 was free of neglect resulting in pressure injuries, which posed a potential health, safety and personal rights risk to 1 (R1) of 71 residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2025

Plan of correction: Administrator agreed to have an outside agency provide in service training to all staff regarding repositioning, monitoring and docuementing wounds. Administrator agreed to submit proof of training to the LPA, by May 8th, 2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Apr 8, 2025

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by: Based on review of records, and interviews, the licensee did not ensure incontinent residetns were kept clean and dry, which posed a potential health, safety, and personal rights risk to 3 residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2025

Plan of correction: Administrator agreed to review policies and procedures regarding incontinece care with all staff. Administrator agreed to submit proof of this training to the LPA, by May 8th, 2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(C) · Plan of correction due date: Apr 8, 2025

87307 Personal Accommodations and Services (a) (3)(C)Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times... This requirement was not met as evidenced by: Based on review of records and interviews, the licensee did not ensure residents had clean linens at all times, which posed a pontential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2025

Plan of correction: Administrator agreed to discuss the importance of having linens on each residents's bed at all times with housekeeping and care staff. Adminstrator will provide documentation to the LPA by May 8th, 2025.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) Wes Hebner. Community Care Licensing received an Incident Report on 2/24/25 in which it was reported that Resident #1 (R1) had been given an extra pill by Staff #1 (S1). Per the report, R1 does take that medication, but is typically given it in the mornings, and the extra dose was given in the evening. R1 reported on 2/17/25 that they were given the extra medication on 3/14/25. Emergency medical services (EMS) were called and Poison Control was called and consulted with. It was decided by EMS and Poison Control that R1 did not need additional medical aid. R1's responsible party was notified of the incident. During today's visit, LPA conducted a health and safety visit with R1 and provided consultation with ED Hebner. A deficiency was cited during the visit. An exit interview was conducted with Business Office Manager Jennifer Flores to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Mar 19, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80075(b) · Plan of correction due date: Apr 2, 2025

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by: Based on file review and interview, the Licensee did not ensure proper medication administration procedures, resulting in a medication error, posing a potential health and safety risk to 1 out of 71 residents in care.the state’s words, verbatim · CDSS document, Mar 19, 2025

Plan of correction: Licensee will submit proof of medication re-training with S1 and submit to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) Wes Hebner. Community Care Licensing received an Incident Report on 3/10/25 in which it was reported that Resident #1 (R1) was observed by staff to have irritation and redness on the face. The resident's relative reported that R1 had washed their face with Ajax cleaning solution left in their bathroom, thinking it was soap. R1 resides in the Memory Care unit of the facility. R1 was taken to urgent care by their responsible party, where they received treatment. R1 has two (2) follow-up appointments scheduled with their Primary Care Physician (PCP). Per the Incident Report, the Ajax solution was immediately removed from R1's room and spot checks were conducted. Upon interview with ED Hebner, the cleaning solution had been left by housekeeping staff either the morning of the incident or evening prior. During today's visit, LPA consulted with ED Hebner and conducted a health and safety check with R1. A deficiency was cited during the visit. An exit interview was conducted with Business Office Manager Jennifer Flores to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Mar 19, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Apr 2, 2025

(a) . . . the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances . . . and other similar items which could pose a danger to residents are in locked storage and are not left unattended . . . This requiement is not met by: Based on file review and interviews, the Licensee did not ensure hazardous cleaning supplies were kept locked and inaccessible to residents in care, posing an immediate health and safety risk to 1 out of 71 persons in care.the state’s words, verbatim · CDSS document, Mar 19, 2025

Plan of correction: Licensee will submit proof of hazardous materials storage/procedures training for housekeeping staff and submit to LPA by POC due date.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Continuation Annual Inspection visit. The LPA introduced himself and disclosed the purpose of the visit to Business Office Manager Jenny Flores. The facility was licensed for a capacity of one hundred twenty (120) non-ambulatory residents, of which ten (10) may be bedridden. The facility also had an approved hospice care waiver for fifteen (15) residents, and the facility's first floor was approved for delayed egress. During today's visit the LPA conducted interviews and reviewed facility records. There were no deficiencies cited on today's date. An exit interview was conducted with Flores, to whom a copy of this report, and Licensee Rights (LIC 9058), were provided via email. An email read receipt confirms the documents were received by Flores.the state’s words, verbatim · CDSS document, Feb 6, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection visit. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Wes Hebner. Maintenance Director Mathew Gomez and Business Office Manager Jenny Flores assisted the LPA during visit. The facility was licensed for a capacity of one hundred twenty (120) non-ambulatory residents, of which ten (10) may be bedridden. The facility also had an approved hospice care waiver for fifteen (15) residents, and the facility's first floor was approved for delayed egress. During today's visit, the LPA conducted a tour of the interior and exterior of the facility. The facility was clean sanitary and in good repair. Resident bedrooms contained the required furnishings, and the call pendants/signal system tested were operational. Faucets tested delivered water within the required range. Carbon monoxide detectors were tested at random and were also operational. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled and stored in a locked area. No pools, nor bodies of water were observed on the premises. Per staff, no firearms nor ammunition were kept at the facility. All pathways were free of obstructions and slip hazards. Review of facility records was initiated, but due to time constraints, an additional visit on a subsequent day in necessary to complete the annual inspection. An exit interview was conducted with Executive Director Wes Hebner, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058), were provided via email. An email read receipt confirms the documents were received by the Executive Director.the state’s words, verbatim · CDSS document, Jan 31, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Executive Director Austin Irwin, identifying herself and stating the purpose of the inspection. This facility serves one-hundred twenty non-ambulatory residents, 60 and above. Approved for Hospice waiver for 15. First floor is approved for delayed egress. A tour of the facility was conducted which included a sample of resident units, the dining area, recreation rooms, and food storage areas. This a three story building with three courtyards on the property. There are no water features on the property. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars and non-skid mats. Hot water temperature in residents’ bathrooms were compliant. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. The facility is operating in accordance with their fire clearance. First aid kit(s) were complete and readily accessible in the medication room. Required licensing postings were observed in visible areas of the facility. PPE supplies are onsite. Passageways were free from obstructions. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed area not assessable to residents. Centrally stored medications were properly stored and locked in medication carts and cabinets. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions. Staff records review verified that all staff records were complete and compliant. Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPA conducted a review of In-service training procedures. LPA interviewed Administrator Irwin and was assured transportation procedures as well as outside medical and dental assistance procedure are compliant. There are two designated activity areas used for such activities as exercise, game activities, arts/crafts, and current events. There are also gathering areas throughout the facility. At the time of visit, LPA observed one large group activities in which many residents were participating. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No deficiencies were issued at the time of visit. An exit interview was conducted with Executive Director Austin Irwin to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 24, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Austin Irwin. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 11/10/2023), involving Resident #1 (R1) on 11/06/2023. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, LPA performed a brief facility tour and welfare check, verifying that R1 was safe. LPA reviewed and collected copies of pertinent care records. LPA also interviewed R1 and relevant staff. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Irwin, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Nov 22, 2023

Allegation investigated: Staff did not treat resident with dignity

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Austin Irwin. Throughout the investigation, the Department secured pertinent records and conducted interviews. It was alleged staff did not treat a resident with dignity. It was reported to the Department someone witnessed a staff member place their hand over a Resident # 1’s (R1) mouth and tell R1 to be quiet. Review of records along with an interview confirmed Staff # 1 (S1) had admitted the incident had occurred. Although, S1 may not have meant any harm to R1, an internal investigation revealed S1 violated company policy. Based on evidence obtained, the allegation was Substantiated, and cited in LIC 9099D. Review of additional records revealed in-service training was conducted for all staff at the facility, after the incident occurred. (See LIC 9099C for continuation of report.) Substantiated An exit interview was conducted with Irwin, to whom a copy of this report, LIC 9099D, Licensee/Appeals Rights (LIC 9058), and clear Plan of Correction Letter, were provided.the state’s words, verbatim · CDSS document, Oct 30, 2023 · control 08-AS-20231005093615

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 30, 2023

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on review of records and an interview, the Licensee did not ensure S1 accorded R1 with dignity in their relationship, which posed a potential health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Oct 30, 2023

Plan of correction: Executive Director provided the LPA proof of in- service training provided to all staff, regarding elder abuse. POC was cleared on today's date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Austin Irwin. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received 09/18/2023). According to the LIC624, during the evening of 09/07/2023, an error by Staff #1 (S1) led to Resident #1 (R1) not receiving one (1) of their medicines as it was prescribed. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, LPA performed a brief facility tour and welfare check on R1, finding that they were safe, alert, and participating in a recreational activity. LPA also interviewed pertinent staff and reviewed relevant care records. Per their latest LIC602 Physician’s Report (dated 08/31/2023), R1 was diagnosed with Mild Cognitive Impairment and required staff assistance with taking their prescribed medications. Manager interview confirmed this. Staff interviews, corroborated by records, showed: On 09/07/2023, S1 gave R1 two (2) tablets, instead of the prescribed one (1) tablet, for one of their medications. Licensee’s staff timely notified R1’s prescribing physician (PCP) of the error, followed PCP instructions, and provided increased observation of R1. The medication error did not result in any adverse health consequence for R1. Personnel and training records showed: Following the incident, Licensee undertook individual written corrective action and retraining with S1. On 09/21/2023, Licensee also retrained its larger medication technician team on accurate medication pass procedures. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] A preponderance of evidence exists to show: During the incident in question, License’s staff (S1) did not give R1 a medication as it was prescribed. The incident did not result in injury or illness to R1. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. LPA also issued one (1) Technical Violation (TV) regarding Reporting Requirements. An exit interview was conducted with Irwin, to whom a copy of this report, the LIC 809-D, the LIC9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Oct 2, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 2, 2023

87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by: Based on records and interviews, the licensee did not assist 1 of 64 residents (R1) with self-administered medications as needed/prescribed, which posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Oct 2, 2023

Plan of correction: Personnel and training records showed: On 09/13/2023, Licensee undertook individual written corrective action and retraining with S1. On 09/21/2023, Licensee also retrained its larger medication technician team on accurate medication pass procedures. These actions resolve the deficiency.