Rancho Vista Senior Living

Type of visit: Case Management - Other

On May 19, 2026, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a Case Management Other, and met with the Administrator, Brian Taube. LPA Mixson introduced herself and explained the purpose of the visit. LPA Mixson toured the facility, along with the Administrator and made observations. There were enough staff present to attend to the residents at the time of this case management visit. There are no imminent health and/or safety concerns observed at the time of visit. The LPA requested and received pertinent documentation pertaining to the facility informing residents of the rent increase. LPA Mixson did not observe any health and/or safety hazards inside or outside of the facility at the time of this visit. LPA observed the facility utilities to be operating without issue. LPA Mixson assessed the available food and observed there was a variety of food types available for the residents in care. The food supply meets the requirement of a two day supply of perishable foods and a seven day supply of non-perishable foods. The medications were found to be in sufficient supply, locked, and inaccessible to the residents in care. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and/or welfare of the residents in care. No deficiencies were observed or cited during today's visit. An exit interview was conducted, and a copy of this report was provided to the Administrator, Brian Taube.the state’s words, verbatim · CDSS document, May 19, 2026

Type of visit: Case Management - Other

On February 25, 2026 Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a case management health and safety visit, and met with the Administrator, Brian Taube. LPA Mixson introduced herself and explained the purpose of the visit. LPA Mixson toured the facility, along with the Administrator and made observations. There were enough staff present to attend to the residents at the time of this case management visit. There are no imminent health and/or safety concerns observed at the time of visit. The LPA requested and received pertinent documentation pertaining to the facility locks on the residents doors in the memory care department. LPA Mixson did not observed any health and/or safety hazards inside or outside of the facility at the time of this visit. LPA observed the facility utilities to be operating without issue. LPA Mixson assessed the available food and observed there was a variety of food types available for the residents in care. The food supply meets the requirement of a two day supply of perishable foods and a seven day supply of non-perishable foods. The medications were found to be in sufficient supply, locked, and inaccessible to the residents in care. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and/or welfare of the residents in care. No deficiencies were observed or cited during today's visit. An exit interview was conducted and a copy of this report was provided to the Administrator, Brian Taube.the state’s words, verbatim · CDSS document, Feb 25, 2026

Type of visit: Required - 1 Year

On February 25, 2026, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Annual Inspection and met with the Administrator, Brian Taube. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for 170 Elderly Adult residents and is currently operating at the capacity of 70 Elderly Adult residents. For a (740) facility type. LPA Mixson toured the facility along with the Administrator, Brian Taube, and made observations pertaining to the required annual visit. LPA inspected the facility inside and outside. There were no obstructions or debris to the indoor or outdoor passageways observed. Additionally, there were no bodies of water seen on the premises at the tie of this visit. The facility is a multi-story building located at 760 East Bobier Drive Vista, Ca. 92084. Physical Plant: The facility phone number is (760) 941-1480, and it is operable. LPA Mixson observed a sample of the residents’ bedrooms, and each was furnished as Regulations and Title 22. LPA Mixson inspected the facility bathrooms, and the hot water temperature tested within regulations, and was logged. The bathrooms were clean, and appliances were operating appropriately currently. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something,” the "Personal Rights," and the LTCO poster. The cleaning supplies and sharp items were locked and inaccessible to the residents in care presently. There was designated storage spaces for the residents’ and staff’s files, and this office was locked and inaccessible to residents in care at present. There elevators were clean and operable at the time of this visit. Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. There were no documented errors observed on the centrally stored medication forms, and medications were stored in their original containers at the time of this visit. Food Service& furniture: The non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents at this time. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked. The kitchen is an industrial style kitchen adjacent to a dining hall where meals are served in a restaurant style setting. Care & Supervision/Administration: There were adequate staff present for the supervision of residents in care. The floor plans, telephone numbers and personal rights were found posted in the facility. The listed Administrator, Brian Taube holds a current administrator’s certificate, and it is posted in the facility. The overall facility is clean; the furniture is in good condition and arranged in a manner which provides space for residents to move safely. The facility cooling system and other appliances were operable at present. Licensee informed LPA there were safety lights for night throughout the facility. There is a receptionist and desk at the front lobby entrance. Records Reviewed and Resident/Staff Files: LPA Mixson reviewed the staff files and the facility's staff schedule. The staff files reviewed had the criminal clearances, updated training's, along with current First Aid certifications. The resident files reviewed possessed the required paperwork as per Regulations at the present, including current TB tests. Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan as well as the disaster training binder. LPA observed the last fire drill met the Department standards and was conducted as required per standards. Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to conduct regular cleaning of the facility. LPA reviewed the facility's infection control plan and found required infection control measures met the Department requirements. An exit interview was conducted. A copy of this report was reviewed and given to the Administrator, Brian Taube.the state’s words, verbatim · CDSS document, Feb 25, 2026

Allegation investigated: Staff neglect resulted in resident sustaining two head injuries Staff neglect resulted in resident sustaining multiple falls Staff did not assist resident with dental hygiene as needed Staff did not provide copy of written admission agreement to resident's responsible person at admission Staff retained a resident beyond their scope of care

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Beatrice and explained the purpose of the visit. Executive Director Diane Domingo was contacted by telephone. On March 15, 2024, Community Care Licensing received a complaint alleging neglect resulted in resident sustaining two head injuries and staff neglect resulted in resident sustaining multiple falls, staff did not assist resident with dental hygiene as needed, staff did not provide a copy of written admission agreement to resident’s responsible person at admission, staff retained a resident beyond their scope of care. LPA conducted interviews with Administrator, staff, and additional witnesses. LPA also conducted a review of pertinent documentation. LPA was unable to interview Resident #1 (R1) to obtain pertinent information due to R1 no longer living at the facility since February 28, 2024. R1’s spouse confirmed that R1 passed away on November 3, 2024. (Continued on Page 2) Unsubstantiated (Continued from Page 1) Regarding the allegation resulted in resident sustaining two head injuries and staff neglect resulted in resident sustaining multiple falls, it was reported that between December 28, 2023, through February 8, 2024, R1 had ten incidents that included falls. R1 was admitted as a fall risk and had an unsteady gait. It was recommended that R1 use a walker. Information obtained from interviews stated R1 did not like to use the walker, and it was also advised that R1 would wander through the facility at night without their walker. R1 had a total of five falls where R1 was found on the side of the bed on the fall mat or found sliding off own bed onto the fall mats, one fall in the dining room where R1 slid off own wheelchair, and the last fall witnessed by R1’s spouse coming out of the bathroom and observed R1 attempting to get up from wheelchair and fell forward. One incident, R1 was walking in the hallway without walker, and feet got crossed causing to trip and fall hitting head, staff assessed and immediately called 911 and another incident, staff witnessed R1 in the dining room where R1 was agitated and threw body forward on wheelchair causing head to hit the floor, staff assessed and immediately called 911. Hospice documents reviewed revealed a low ground hospital mattress, halo rails and fall matt were in placed along with a walker and a wheelchair, due to R1’s anxiety and agitation, medication were noted to be ineffective by hospice. Regarding the allegation staff did not assist resident with dental hygiene as needed, it was reported that R1 sustained a mouth infection due to staff not taking his partial out when brushing his teeth. Based on staff and resident interviews it was revealed residents are helped by staff according to their needs. A review of facility records, R1’s needs and services plan dated December 28, 2023, requested assistance with personal hygiene for dental care, in which it was provided by staff. Regarding the allegation staff did not provide a copy of written agreement to resident’s responsible person at admission, it was reported requested and just now provided. Based on staff and resident interviews it was revealed residents and their responsible parties are provided a copy of written agreements. A review of facility records did reveal R1’ responsibility party signed documents December 19, 2023. (Continued on Page 3) (Continued from Page 2) Regarding the allegation staff retained a resident beyond their scope of care, it was reported the facility neglected to meet R1’ needs as a fall risk. Based on staff and residents interviews it was revealed that the facility took all precautions to prevent falls risks. A review of facility records, R1 was on hospice and a care meeting involved R1’S responsible party, hospice agency and facility to assist R1 with additional services and there were many fall precautions and prevention strategies put in place for R1 during the time frame at the facility. Based on staff interviews, witness interview, hospital records, facility records, the allegation Neglect Lack of Care and supervision resulted in resident sustaining multiple falls and Neglect Lack of Supervision resulted in resident sustaining two head injuries, staff did not assist resident with dental hygiene as needed, staff did not provide a copy of written admission agreement to resident’s responsible person at admission, staff retained a resident beyond their scope of care is unsubstantiated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Beatrice Pena and Diane Domingo by telephone and a copy of this report along with LIC811- Confidential Names list was provided.the state’s words, verbatim · CDSS document, Jun 11, 2025 · control 18-AS-20240315160442

Allegation investigated: Lack of supervision resulted in resident sustaining an injury and hospitalization Lack of supervision resulted in resident left on the floor for an extended amount of time Staff did not ensure resident was provided fluids resulting in dehydration Staff did not give resident's medication as prescribed Staff did not ensure resident was nourished Staff did not assist resident with CPAP machine Resident did not have a call assistance button or a pendant Staff left resident in wet briefs for an extended period of time resulting in sores Facility’s screen door was in disrepair

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Diane Domingo and explained the purpose of the visit. On January 26, 2024, Community Care Licensing received a complaint alleging lack of supervision resulted in resident sustaining an injury and hospitalization and lack of supervision resulted for staff failing to seek timely medical, Staff did not ensure resident was provided fluids resulting in dehydration, staff did not give resident’s medication as prescribed, staff did not ensure resident was nourished, staff did not assist resident with CPAP machine, resident did have a call assistance button or pendant, staff left resident in wet briefs for an extended period of time resulting in sores, facility’s screen door was in disrepair. LPA conducted interviews with Administrator, staff, residents, and additional witnesses. LPA also conducted a review of pertinent documentation. (Continued on Page 2) Unsubstantiated (Continued from Page 1) LPA was able to interview Resident #1 (R1) to obtain pertinent information due to R1’s current cognitive impairment, R1’s interview could not corroborate allegations. Regarding the allegation lack of supervision that resulted in resident sustaining an injury that caused hospitalization, R1 was found on the floor by staff and was immediately assessed and 911 was called and was taken to the hospital and discharged to a Skilled Nursing Facility for two and half months and returned to Pacifica November 8, 2023. On December 13, 2023, R1 had a lumbar procedure outpatient and from the procedure was weak in recovery and activities started to decease. R1 was at the facility for seven weeks due to R1’s multiple hospitalization's, procedures and rehabilitations and early removal from the facility. Regarding the allegation staff did not ensure resident was provided fluids resulting in dehydration, based on staff interviews, staff would provide R1 with water, juice, or smoothies and at times R1 would refuse to drink liquids that were offered, a review of R1’s assessment dated 11/08/2023 stated R1 was independent in feeding self. Regarding the allegation staff did not give resident’s medication as prescribed, based on staff interviews, R1 was on medication management and staff would take R1’s medication to R1 to take and R1 would refuse to take medications sometimes, staff would give R1 some time and would return with the medication to take, a review of R1’s facility records, an assessment and Physician’s Report revealed R1 needed prompting assistance with medication management. Regarding the allegation staff did not ensure resident was nourished, based on staff interviews, R1 was prepare meals and sometimes meals were brought to R1 at bedside if R1 did not want to go to the dining area and R1 at times would not eat the food and did not want to be bothered at times, R1 was always provided meals and snacks. A review of facility records, an assessment stated that R1 was able to eat independently. (Continued on Page 3) (Continued from Page 2) Regarding the allegation staff did not assist resident with CPAP machine, based on staff interviews, R1 did have a CPAP machine, and staff was aware of R1 having to use CPAP machine at night and at times R1 would refuse assistance from staff with wearing the machine and sometimes would be found during checks not wearing the machine. A review of facilities records for R1, a needs and services plan stated resident uses a CPAP machine at night. Regarding the allegation resident did not have a call assistance button, based on staff, resident and witnesses interviews it was revealed resident rooms are equipped with emergency call system and pendants are available to residents if they choose. A review of facility records did not reveal on R1’ admission agreement that a pendant was requested or issued to R1. Regarding the allegation staff left resident in wet briefs for an extended period resulting in sores, based on staff and witnesses interviews, any resident who needs assistance with incontinence care will be check, assessed and changed, it was revealed at times that R1 would not want assistance from staff, R1 would become verbally aggressive with staff, staff would give R1 some time and return to do the assistance with R1’s toileting needs. A review of facility records revealed R1’s assessment stated that R1 needed assistance with toileting and no corroborating documentation of R1 resulting in sores. Regarding the allegation facility’s screen door was in disrepair, based on staff, residents, and witnesses’ interviews, it was revealed there are sliding glass doors with sliding screen doors that designed to open to 6 inches as a safety precaution for residents in the building. LPA corroborated sliding glass doors and sliding screen doors opening to 6 inches for rooms. (Continued on Page 4) (Continued from Page 3) Based on staff interviews, witness interview, facility records, the allegation that Neglect Lack of Care and Supervision for resident’s unwitnessed fall and sustained a fracture that required hospitalization and Neglect Lack of Care and Supervision for staff failing to seek timely medical, Staff did not ensure resident was provided fluids resulting in dehydration, staff did not give resident’s medication as prescribed, staff did not ensure resident was nourished, staff did not assist resident with CPAP machine, resident did have a call assistance button or pendant, staff left resident in wet briefs for an extended period of time resulting in sores, facility’s screen door was in disrepair is unsubstantiated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Diane Domingo and a copy of this report along with LIC811- Confidential Names list was provided.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 18-AS-20240126104012

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility with LPA identification and business card. Resident record review began- Ten (10) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. Employee records review began- Six (6) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and renewed on 2/26/2025 and still processing. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The buildings are maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 110.0 degrees F. Laundry is done in the designated laundry room located on the 2nd floor of building B. There is a locked closet for storing laundry soap and other chemicals in the housekeeper’s closet on the 2nd floor All outdoor and indoor passageways are free of obstruction. (Continued on next page) Continued on from Page 1) There is a location for sharps in the kitchen. LPA verified there is a telephone working at this location. There are no firearms stored and no bodies of water observed. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training. Food Service- Food supply meets the requirement of one week supply of nonperishable and 2-day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation, and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors are tested quarterly 2/12/2025 for ten (10) buildings and LPA observed report from Dialcom Systems Group Inc. were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 1/6/2025. The facility is conducting emergency disaster drills monthly. The last disaster drill was conducted on 03/28/2025. Based on the information received during this visit today, there are no deficiency that is being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with Diane Domingo and a copy provided at the time of the exit interview.the state’s words, verbatim · CDSS document, Apr 24, 2025

Allegation investigated: Facility does not have sufficient staff to meet the care needs of residents. Staff does not ensure facility has sufficient quantity of food for residents in care. Staff do not ensure proper sanitary practices are followed while providing bathing services to residents in care.

On 03/30/25 at 8:10 am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Executive Director Diane Domingo as the purpose of today’s visit was explained. The investigation consisted of the following: On 03/29/25 LPA Villegas obtained copies of the resident roster, list of residents that require bed baths, facility menus dated January 2025, February 2025, and March 2025, alternative menu, and requested copies of the following documents for resident #1 (R1) emergency ID form, physicians report dated: 10/3/23, physicians orders dated: 8/15/23, PRN authorization form dated 8/23/23, needs and service plan dated: 4/14/23. On 03/29/25 LPA conducted a tour of the facility kitchen and observed the lunch service from 11:15am- 12pm. On 03/29/25 between 1pm-3pm LPA conducted Interviews with staff #1-7 (S1-S7), and between 3pm-3:25pm LPA conducted interviews with resident# 1-5 (R1-5). On 03/29/25 LPA conducted a file review for R1s file. On 03/30/25 LPA obtain a copy of the staff roster, transportation schedule, appointment book, hospice notes, and facilities driver file. Unsubstantiated The investigation revealed the following: Allegation: Facility does not have sufficient staff to meet the care needs of residents. It is being alleged that facility does not have sufficient staff to operate the facility transport vehicle. On 03/29/25 between 1pm-3pm LPA conducted Interviews with S1-S7 regarding the allegation above, 5 of 7 staff interviewed denied the allegation above, 2 of 7 staff interviewed reported being unaware of transportation procedures or schedules. On 03/29/25 between 3pm-3:25pm LPA conducted interviews with resident R1-R5, 4 of 5 residents interviewed denied the allegation above, 1 of 5 residents interviewed confirmed the allegation above and stated resident has been unable to obtain the care needed due to transportation. On 03/30/25 LPA conducted a review of LIC 500 dated 03/18/25, LPA observe facility driver to be scheduled 5 days a week from 8:30am-5pm. On 03/30/25 LPA conducted a review of appointment calendar and appointment book, LPA observed R1 to be scheduled for transportation between 2-4 times a month. Allegation: Staff does not ensure facility has sufficient quantity of food for residents in care. It is being alleged that the facility has ran out of food 3 times during dinner service. On 03/29/25 LPA conducted a tour of the facility kitchen and observed the dry pantry, refrigerator, and freezer to be fully stocked and labeled with expiration dates. On 03/29/25 during kitchen tour LPA also observed food delivery taking place. On 03/29/25 between 1pm-3pm LPA conducted Interviews with S1-S7 regarding the allegation above, 7 of 7 staff interviewed denied the allegation above and reported residents can obtain additional food upon request, 2 of 7 staff interviewed also added that the kitchen receives food deliveries 2 times per week. On 03/29/25 between 3pm-3:25pm LPA conducted interviews with resident R1-R5, 4 of 5 residents interviewed denied the allegation above, 1 of 5 residents interviewed confirmed the allegation above and stated resident has gone 3 days without obtaining food. On 03/29/25 LPA conducted a review of R1's narrative charting dated February 2024-March 2024 that R1 refuses meal service completely or resident consumes very little to no food from tray. Allegation: Staff do not ensure proper sanitary practices are followed while providing bathing services to residents in care. It is being alleged that residents who require bathing assistance in their bed get their face washed using the same water that was used in the bowl for the rest of their body. On 03/29/25 between 1pm-3pm LPA conducted Interviews with S1-S7 regarding the allegation, 5 of 7 staff interviewed denied the allegation above and reported bed baths are conducted by hospice nurses, 2 of 7 staff interviewed reporting having no knowledge of bathing procedures. On 03/29/25 between 3pm-3:25pm LPA conducted interviews with resident R1-R5 regarding the allegation above, 4 of 5 residents interviewed denied the allegation above and reported not needing shower assistance and having no concerns with the water used for hygiene purposes. 1 of 5 residents interviewed confirmed the allegation above and reported not having a shower for over 3 days. On 03/30/25 LPA conducted a review of hospice notes from October 2024- March 2025 for R1, LPA observed documentation reporting R1 has received 2-3 bed bathes from hospice nurse upon agreement as it is also documented that R1 has refused hospice nurse assistance. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 30, 2025 · control 18-AS-20240327103809

Allegation investigated: Staff yelled at another staff member in the presence of multiple residents. Staff made residents feel uncomfortable.

On 03/30/25 at 8:15 am Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Executive Director Diane Domingo as the purpose of today’s visit was explained. The investigation consisted of the following: On 03/29/25 LPA Villegas obtained copies of the resident roster, and requested the following documents for resident #1 (R1): emergency ID form, physicians report dated: 4/6/23, physicians orders dated:8/15/23, PRN authorization letter dated: 8/22/23, preplacement appraisal dated: 11/8/22, needs and service plan dated: 12/7/23, resident assessment dated: 12/7/23, medication refusal notifications dated: 7/3/23, 7/9/23, 7/20/23, 7/30/23, 8/7/23, and documentation on increase/transfer/level of care dated 6/5/23. on 3/25/25 LPA conducted phone interview with R1, on 03/29/25 from 1pm-3pm LPA conducted Interviews with staff #1-7 (S1-S7), and between 3pm- 3:25pm LPA conducted interviews with resident # 2-5 (R2-R5). On 03/30/25 LPA obtain a copy of the staff roster. Unsubstantiated The investigation revealed the following: Allegation: Staff yelled at another staff member in the presence of multiple residents. It is being alleged that former Executive Director yelled at a staff in the presence of 2 residents in care. On 03/29/25 from 1pm-3pm LPA conducted Interviews with S1-S7, 6 of 7 staff interviewed denied the allegation above, 1 of 7 staff interviewed confirmed the allegation above and reported that 2 staff members were arguing by the dinning room, and nothing was done to diffuse. On 3/25/25 and 03/29/25 LPA conducted interviews with R1-R5 regarding the allegation above, 4 of 5 residents interviewed denied the allegation above, 1 of 5 residents interviewed reported resident did not observe the allegation above, but the information was disclosed by peers. Allegation: Staff made residents feel uncomfortable. It is being alleged that residents felt uncomfortable due to staff yelling. On 03/29/25 from 1pm-3pm LPA conducted Interviews with S1-S7, 7 of 7 staff interviewed denied the allegation above and reported treating all residents in care with respect and dignity. On 3/25/25 and 03/29/25 LPA conducted interviews with R1-R5 regarding the allegation above, 4 of 5 residents interviewed denied the allegation above and reported feeling safe around staff, 1 of 5 residents interviewed confirmed the allegation above and reported feeling uncomfortable as resident was yelled at by a facility staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 30, 2025 · control 18-AS-20230727083953

Allegation investigated: Staff handles resident in a rough manner. Staff threatens resident. Staff does not treat resident with dignity and respect. Staff stole resident’s personal belongings.

On 3/30/2025 at approximately 8:15 AM, LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. At approximately 8:30 AM, LPA Iniguez met with Diane Domingo / Executive Director. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA obtained and reviewed the following documents: Personnel Report or LIC 500 dated: 3/18/25, (R#1)’s Physicians Report for Residential Care Facilities for the Elderly or LIC 602A dated: 10/3/24 and (R#1)’s, (R#1)’s Client/Resident Personal Property and Valuables or LIC 621 dated: 12/5/23, (R#1)’s Inventory List from hospital dated: 11/27/23, and facility staff training records regarding residents personal rights dated: 2024. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff handles resident in a rough manner. The details of the complaint alleged that facility staff throw (R#1) in bed in roughly manner. On March 29, 2025, at approximately 9:00 AM, during a review of records, LPA Iniguez examined the hospital discharge records for (R#1) dated: 7/7/24. On 7/7/24, (R#1) went to the hospital due to shortness of breath (SOB) via ambulance. In the social work notes, LPA Iniguez noted that both the doctor and the registered nurse indicated that there was no physical evidence of trauma found during this hospital visit. In addition, LPA Iniguez observed (R#1)’s Physicians Report for Residential Care Facilities for the Elderly or LIC 602A dated: 10/3/24. In the report it is noted that (R#1)’s has a cognitive condition that may influence their behavior. On March 29, 2025, at approximately 10:30 AM, during an interview with the Administrator (A#1), she stated that the facility staff receives training on residents' personal rights annually and upon hiring. Furthermore, (A#1) mentioned that the facility staff did not mishandle resident (R#1) or any other residents in their care. An addition, (A#1) stated that she did not provide direct care to (R#1) or any other residents in care. On March 29. 2025, at approximately 11:50 AM, during an interview with (R#1) by bedside, (R#1) stated that they do not recall the time and date when the “male administrator “threw them into the bed roughly. On March 29, 2025, at approximately 3:00 PM, during interviews with residents (R#1-R#5), (4) out of (5) stated that the facility staff had not handled them roughly. On March 29, 2025, at approximately 2:00 PM, during interviews with facility staff (S#1-S#5), (5) out of (5) stated that they received training every year regarding residents’ rights. Also, (5) out of (5) facility staff stated that they have not handled (R#1) or any other resident in care in a rough way. Evaluation Report continues LIC 9099-C Allegation: Staff threatens resident. The details of the complaint alleged that facility administrator threatened (R#1) to “make it harder” for them at the facility. On March 30, 2025, at approximately 11:30 AM, during records review LPA observed (R#1) admissions agreement dated 11/27/23, it is written that if (R#1) desires to leave facility a 30-day notice needs to be done. On March 29, 2025, at approximately 10:30 AM, during an interview with Administrator (A#1), she stated that she had not threatened (R#1) or any other residents in any way. In addition (A#1) stated that if a resident wishes to leave the facility a 30-day noticed if required. On March 29. 2025, at approximately 11:50 AM, during an interview with (R#1) by bedside, (R#1) stated that the male administrator threatened them to “make it harder for them”. (R#1) was not able to give more details about this allegation. On March 29, 2025, at approximately 3:00 PM, during interviews with residents (R#1-R#5), (4) out of (5) stated that they have not been threatened by facility administrator in any way. On March 29, 2025, at approximately 2:00 PM, during interviews with facility staff (S#1-S#5), (5) out of (5) stated that they had not seen or heard the facility administrator threaten (R#1) or any other resident in care in any way. Evaluation Report continues LIC 9099-C Allegation: Staff does not treat resident with dignity and respect. The details of the complaint alleged that facility staff makes fun of (R#1) On March 29, 2025, at approximately 10:00 AM, LPA Iniguez requested copies of facility staff training regarding resident personal rights; facility staff stated that these records would be provided late today or on 3/30/25. On March 30, 2025, at approximately 9:30 AM, LPA Iniguez reviewed facility staff online-in-service training dated 2024. LPA Iniguez observed that all facility staff have completed the online Resident Rights & Abuse Reporting course v.1. On March 29, 2025, at approximately 10:30 AM, during an interview with the Administrator (A#1), she stated that the facility staff, including herself, provide resident (R#1) and the other residents with dignity and respect during interactions. On March 29. 2025, at approximately 11:50 AM, during an interview with (R#1) by bedside, (R#1) stated that the facility staff made “fun of them”. (R#1) was unable to provide names of facility staff or what has been said during this interaction. On March 29, 2025, at approximately 3:00 PM, during interviews with residents (R#1-R#5), (4) out of (5) stated that the facility staff treats them with dignity and respect, and they did not On March 29, 2025, at approximately 2:00 PM, during interviews with facility staff (S#1-S#5), (5) out of (5) stated that they treated (R#1) and all the residents in care with dignity and respect. Evaluation Report continues LIC 9099-C Allegation: Staff stole resident’s personal belongings. The detail of the complaint alleges that facility staff had stolen (R#1) curtains from their room. On March 30, 2025, at approximately 9:00 AM, during the records review, LPA Iniguez observed (R#1)’s Inventory list from hospital discharge paperwork dated 11/27/23. LPA Iniguez observed that the inventory list does not show any items listed. In addition, LPA Iniguez reviewed the (R#1) Client/Resident Personal Property and Valuables or LIC 621 dated 12/5/23; also, there are no items listed in this form. On March 29, 2025, at approximately 10:30 AM, during an interview with the administrator (A#1), she stated that the facility staff is not stealing (R#1) or neglecting other residents' care of their personal belongings. In addition, (A#1) stated that the theft and loss policy is in place. On March 29. 2025, at approximately 11:50 AM, during an interview with (R#1) by bedside, (R#1) stated that the facility staff sole all the curtains from their room. However, LPA Iniguez observed that blinds were set up in (R#1)’s room. On March 29, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#5), (4) out of (5) stated that they don’t believe facility staff are taking their personal belongings. On March 29, 2025, at approximately 2:00 PM, during interviews with facility staff (S#1-S#5), (5) out of (5) stated that they did not take (R#1)’s or other residents in care personal belongings. Evaluation Report continues LIC 9099-C During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Crystal Naranjo/Memory Care Coordinator.the state’s words, verbatim · CDSS document, Mar 30, 2025 · control 18-AS-20240708162702

Allegation investigated: Facility failed to provided a comfortable environment for resident.

On 03/20/25, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent unannounced complaint visit to the facility above. LPA met with Executive Director (ED) Diane Domingo and explained the purpose of today's visit. The investigation consisted of the following: On 03/29/25, at 8:30 am, LPA obtained copies of the resident roster and facility roster. On 03/29/25, between 1:00 pm and 2:00 pm, LPA interviewed five (5) residents #2, (R2-R6), and between 2 00 pm to 3: 30 pm, LPA interviewed six (6) staff, #1-6, (S1-S6), and (ED)Diane Domingo and other pertinent records associated with this complaint. On 03/30/25, at 8:30 am LPA, Richard reviewed and obtained the following documents for resident #1 (R1): Admission Agreement (dated 12/13/22), Physician report (dated 12/16/21), and Needs and Service Plan LIC625 (dated 01/19/21). LPA was unable to interview Resident #1 (R1), as R1 passed away on 04/18/2023. Unsubstantiated Allegation: The facility failed to provide a comfortable environment for residents. This complaint alleges the facility had construction occurring above the resident's (R#1s) room and this disturbed the resident. On 03/29/25, between 1:00 pm and 2:00 pm, LPA Richard interviewed five (5) Residents, #2-6 (R2- R6). LPA found, 5 out of 5 denied the allegations and did not state hearing noises due to construction. The residents did not express issues with the facility being unsafe and an uncomfortable environment. LPA conducted interviews with three (3) residents (R1-R3), and 3 out of 3 stated that while living at the facility, they have not noticed construction occurring. On 03/29/25, between 2:00 pm and 3:30 pm, LPA interviewed six (6) staff #1-6 (S1- S6). LPA found, 6 out of 6 denied the allegation and stated that the facility is safe and comfortable for residents. On 03/29/25, between 2:00 pm and 3:30 pm, LPA interviewed with Business Director (BD) John McGregory, who stated that there was no construction going on at the facility on 03/09/23. The BD stated the facility was painting room #148, which is located above room #120 (R#1s room). BD #1 stated that there was no excessive noise occurring while the painting was performed in Room #148. Additionally, BD #1 stated he received no concerns placed by residents when the painting was performed in Room #148. Based on LPA’s observations, and interviews, LPA did not find sufficient evidence to support the allegation that, facility failed to provide a comfortable environment for residents. Although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged allegation is valid or did occur, therefore, the allegation is Unsubstantiated. No deficiencies were cited. Exit interview conducted. A copy of this report was provided to the Executive Director Diane Domingo.the state’s words, verbatim · CDSS document, Mar 30, 2025 · control 18-AS-20230309130057

Allegation investigated: Facility does not provide meals in the quantity necessary for resident

/30/2025, at 8:15 am, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent unannounced complaint visit to the facility above. LPA met with the Executive Director, Diane Domingo, and explained the purpose of today's visit. The investigation consisted of the following: On 03/30/25, LPA obtained copies of the resident roster, staff roster, facility menus (dated January 2025, February 2025, and March 2025), and a copy of the alternative meal menu. On 03/29/25, between 11:00 am and 12:00 pm, LPA Richard toured the kitchen and observed lunch being served. On 03/29/25, between 1:00 pm and 2:00 pm, LPA interviewed five (5) residents #2 (R2- R6). Between 2:00 pm 3 and 30 pm, LPA interviewed six (6) staff, #1-6 (S1-S6), Executive Director Diane Domingo (ED), and other pertinent records associated with this complaint. On 03/30/25, LPA Richard reviewed and obtained copies of the following documents for Resident #1 (R1): Admission Agreement (dated 03/05/2023), Physician Report (dated 05/24/2023), and Needs and Service Plan LIC625 (dated 012/30/22). LPA was unable to interview Resident #1 as R1 no longer resides in this facility. Unsubstantiated Allegation: Facility does not provide meals in the quantity necessary for residents. This complaint alleges that the facility does not provide sufficient portion sizes to residents. On 03/29/25, between 1:00 pm and 2:00 pm, LPA Richard interviewed five (5) Residents, #2-6 (R2- R6). LPA found, Five out of five denied the allegations and stated that the facility serves good-quality food and ample servings. Five out of five residents stated that they could ask for a second serving if they were not full. The residents stated the facility served them three meals a day and snacks between meals. On 03/29/25, between 2:00 pm and 3:30 pm, LPA interviewed six (6) staff, #1-6 (S1- S6), and found 6 out of 6 staff stated that the meals served were sufficient portion sizes. Staff interviewed stated that Residents can ask for a second serving of food when requested. Additionally, 6 out of 6 staff members stated that the residents are served high-quality, nutritious meals with various options, and no resident has complained to staff about not being served enough food. On 03/29/25, at 2:00 pm, LPA interviewed the Executive Director (ED)/ Domingo, who denied the allegation and stated that the facility provides sufficient food to residents daily. ED/Domingo states the facility food items are consistently stocked, and food delivery occurs two times per week to ensure food items are replenished. On 03/29/25, between 1:00 pm to 2 pm, LPA Richard reviewed the facility's menu (dated 02/02/25 to 03/29/25), and this revealed the facility had various food options. LPA Richard observed that the facility food supply exceeds a month of perishables and three days of non-perishables in stock. LPA Richard also observed the resident lunch period and found the food served appeared to be ample in portion size. Based on LPA's observations, interviews, and record reviews, LPA did not find sufficient evidence to support the allegation that the facility does not provide meals in the quantity necessary for residents. Although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove that it is valid or did occur; therefore, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to Executive Director Diane Domingo.the state’s words, verbatim · CDSS document, Mar 30, 2025 · control 18-AS-20231016150752

Allegation investigated: Insufficient staff resulting in staff not checking on residents

On 03/29/2025, the California Department of Social Services (CDSS) Community Care Community Care Licensing (CCL) Licensing Program Analyst (LPA) Socorro Leandro conducted an initial unannounced complaint visit. LPA Leandro met with Sales Director, Alma Chavez and the purpose of the visit was explained. LPA was granted entry to the facility. The investigation consisted of the following: On 01/30/2024, a facility tour was conducted. On 03/29/2025, a facility tour was conducted, records were reviewed, and interviews were conducted. The facility tour consisted of 8 resident rooms. Interviews conducted consisted of 7 staff interviews [Staff (S1) to Staff 7 (S7) were interviewed] and 8 resident interviews (R1 to R8 were interviewed). Facility records reviewed consisted of Rancho Vista Senior Living Census 2025 and Staff Schedule for February 2025, March 2025, and April 2025. Substantiated The investigation revealed the following: Allegation: “Insufficient staff resulting in staff not checking on residents”, it is being alleged that caregivers are not checking in on residents during pm shift and overnight hours. Interviews conducted with R1 to R8 revealed the following: 8 out of 8 residents disagree with the allegation. Interviews conducted with S1 to S7 revealed the following: 4 out of 3 staff agreed with the allegation. Records reviewed revealed the following: Upon review of the Staff Schedule from February to April 2025 for the PM shift that starts from 2:30 PM to 10:30 PM it depicts that 2 caregivers and 1 medical technician are on shift but through close review of documents LPA Leandro observed that only 1 caregiver and 1 medical technician were on shift. Upon review of the Staff Schedule for the months of February 2025 to April 2025 for the NOC shift starts from 10:30 PM to 6:30 AM it depicts that 1 caregiver and 1 medical technician are on shift, however through close review of the documents, LPA Leandro observed that for 8 days in the month of February 2025 there was only 1 staff were on shift and for the month of April 2025 there are 4 days were only 1 staff is scheduled and there are 4 days were there are no staff scheduled. Records review of the Rancho Vista Senior Living Census 2025 in the Assisted Living Unit demonstrates that there are 41 residents in that unit. Interviews conducted with staff indicated that from the 41 residents there are 10 residents who require incontinence care.Substantiated: Based on LPAs interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, a copy of this report was left with the Sales Director, Alma Chavez along with their appeal rights. The investigation revealed the following: Allegation: “Staff do not treat residents with respect”, it is being alleged that staff do not treat residents with dignity and respect. Interviews conducted with R1 to R8 revealed the following: 8 out of 8 residents denied the allegation. Interviews conducted with S1 to S7 revealed the following: 6 out of 7 staff denied the allegation. Observations on 1/30/2024 and 3/29/2025 revealed the following: staff/caregivers were observed treating residents with dignity and respect. Based on interviews and observations this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was left with the Sales Director, Alma Chavez.the state’s words, verbatim · CDSS document, Mar 29, 2025 · control 18-AS-20240123120244

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 8, 2025

Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by: Based on records and interviews the licensee did not comply with the section cited above. 4 out of 7 staff agreed with allegation and records reviewed indicated that the facility at times has 1 staff for 41 residents and 10 of those residents require incontinence care. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2025

Plan of correction: The Sales Director agreed to come up with a plan with her Administrator to increase the PM and NOC shift personnel. Email documents below to CCLD as Proof of Correction. Plan to increase PM and NOC shift staff Plan to meet the requirements for CCR87411(a) Personnel Record LIC500 Proof of Correction will be emialed to Socorro.Leandro@dss.ca.gov

Type of visit: Case Management - Deficiencies

On 3/29/2025 at approximately 3:30 PM, LPAs Alfonso Iniguez, Lizeth Villegas, Socorro Leandro, and Antonine Richards conducted an unannounced subsequent complaint visit. LPAs met with Alma Chavez, the sales director, and explained the purpose of their visit. During the complaints investigation, LPAs were not able to access some of the records needed to investigate the allegations. Facility staff stated that some records were locked in the executive director’s office, and no other facility staff had access to them. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: -Records not available upon demand. -Not Administrator Designee. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Alma Chavez/Sales Director.the state’s words, verbatim · CDSS document, Mar 29, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87755(c) · Plan of correction due date: Apr 14, 2025

87755 Inspection Authority of the Licensing Agency (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b). This requirement was not met by: Based on observations and interviews, the licensee fail to ensure that records were not avalilable upon demand from licensing agency. This poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2025

Plan of correction: Licensee will adhere to title 22 Regulations at all times. As plan of correction, executive director will create a plan and send it to LPA Iniguez via email before POC due date. Licensee will adhere to Title 22 Regulations at all times. As plan of correction, executive director will choose a designee and send proof to LPA Iniguez via email before POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Apr 14, 2025

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement was not met by: Based on observations and interviews, the licensee fail to ensure that there is not a designee administrator at the facility when the executive director is not available. This poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2025

Allegation investigated: Staff do not meet resident's dietary needs Staff did not meet resident's toileting needs Staff did not answer resident's call button in a timely manner

On February 26, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility to deliver the allegation findings and met with Business Office Manager, Jhonalyn Libunao. On April 25, 2023, Community Care Licensing received a complaint alleging that staff are not meeting resident’s dietary and toileting needs and staff do not answer resident’s call button in a timely manner. During the investigation LPA conducted interviews, record reviews, and made observations. It was reported that staff left Resident #1 (R1) sitting on the toilet for 30 minutes or more. It was also reported that it takes facility staff an extended amount of time to answer call buttons. Concerns were also reported that R1 was being charged for a puree diet but was not receiving pureed foods. Unsubstantiated Regarding the allegation staff did not meet resident’s toileting needs, it was reported that on April 4, 2023, staff left R1 sitting on the toilet 30 minutes or more. Information obtained from interview with Administrator, Mike McCoy stated he was not advised of any issues or concerns regarding R1 needing assistance. It was advised that at the time of admission, R1 was independent and did not require assistance with toileting. Information obtained from staff interviews stated that they see R1 two to three times a week and that R1 has not shared with them that they were left unattended while in the restroom. Information obtained from interview with R1 stated that they can still use the restroom without assistance and that they did not recall pressing the call pendant while on the toilet. An interview with R1’s Hospice Nurse was conducted and advised that R1 is seen two to three times a week and R1 did not inform them of any issues or concerns regarding need assistance with toileting. A review of R1’s Admission Agreement confirmed there were no notations indicating R1 required assistance with toileting needs. LPA’s review of the records verified that R1 was not incontinent at time of admission or requested assistance with toileting services during placement. Regarding the allegation staff did not answer resident’s call button in a timely manner, it was reported that it takes an extended amount of time for facility staff to answer the call button. Information obtained from interview with the Administrator stated R1 has not brought it to management’s attention that R1 pressed their call pendant and that no caregiver responded. Information obtained from interviews with facility staff and was advised that R1 did not advise of any concerns. Staff stated call buttons are answered as quickly as possible. Information obtained from interview with R1 stated they do not recall utilizing the call button and not receiving assistance. Regarding the allegation staff do not meet resident’s dietary needs, information obtained from interview with Administrator advised that R1 does not have any type of special diet and no food restriction that the management team is aware of. Additional information obtained from interview with facility staff advised that R1 eats solid foods and does not require a special diet. LPA observed R1 in the dining hall on eating solid foods. LPA conducted a review of R1’s Physician’s Report and there were no information regarding R1 requiring a special diet. Based on interviews, record reviews, and observations, the allegations that staff do not meet resident's dietary needs, staff did not meet resident's toileting needs, and staff did not answer resident's call button in a timely manner, are unsubstantiated. A finding of unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of this report was explained and provided to Business Office Manger, Jhonalyn Libunao.the state’s words, verbatim · CDSS document, Feb 26, 2025 · control 18-AS-20230425102920

Allegation investigated: - Facility did not allow resident to choose hospice service

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by concierge Terri Park. LPA stated the purpose of the visit and reviewed the findings of the complaint with Angeles Frasier, Resident Service Coordinator. The Department’s investigation consisted of interviews with staff and outside sources, and records review of relevant documents pertinent to this investigation. On August 30, 2021, it was alleged that the facility denied resident from receiving hospice services of their choosing. It was alleged the resident's #1 (R1) hospice agency was denied access to see the resident by facility staff when they arrived to provide R1 with their initial services. During the initial visit on September 1, 2021, LPA spoke with the now-former Executive Director (ED), Karen Enciso, who informed LPA the resident did not have a hospice order on file and needed to verify the information; Unsubstantiated (Continuation of LIC9099) they also needed to inquire with the resident’s direct power of attorney’s (DPOA) preference, which was verified. It was noted the former ED was aware the hospice services rendered to residents were the choice of residents and families. An interview with the Long-Term Care Ombudsman (LTCO) did not observe former issues annotated or have current concerns relating to residents' inability to receive services from their hospice agency or visitors. According to the license, the facility has a hospice waiver approved for 25. Upon review of the facility’s visitor log sheets dated August 19, 2021, through August 31, 2021, a registered nurse conducted their initial visit to R1 on August 27, 2021, and it was determined there were two additional visits conducted by the hospice agency for the remainder of the month, August 28th and 31st, 2021. According to the Communication Update log, the DPOA’s chosen hospice services admitted R1 into hospice for routine level of care during their initial visit, on August 27, 2021. Two additional visits were documenting the reason(s) for their visit which was routine care. According to R1 Physician’s Report (LIC 602), dated August 3, 2021, they were diagnosed with a cognitive impairment and were not under hospice care. A second LIC 602, dated August 27, 2021, said R1 was receiving hospice care. According to the hospice Staff Sign-In Sheet and the calendar for August 2021, the agency commenced services on August 27, 2021. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside source interviews and records reviewed, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Angeles Frasier, Resident Service Coordinator. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to Resident Service Coordinator Frasier at the conclusion of the visit. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, Feb 26, 2025 · control 08-AS-20210830151620

Allegation investigated: - Unlawful Eviction(s)

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by concierge Terri Park. LPA stated the purpose of the visit and reviewed the findings of the complaint with Angeles Frasier, Resident Service Coordinator. The Department’s investigation consisted of interviews with staff and outside sources, and records review of relevant documents pertinent to this investigation. On February 15, 2022, it was alleged the facility unlawfully evicted resident(s). It was alleged resident #1 (R1) was unlawfully being evicted from the facility due to an underlying medical condition the facility was aware of and rendering services for. During the initial visit on February 17, 2022, LPA spoke with the Executive Director, Michael McCoy, who informed LPA the facility had sent the residents’ families a notice that was not meant to be served as an eviction. (Continuation on LIC9099-C) Unsubstantiated (Continuation of LIC9099) They were aware any evictions would need to be individualized. Staff #1 (S1) said that they are aware that only the notice was sent out. The facility did not evict any residents when the notice was sent out. They worked with the families to find alternatives for their medications. The facility was removing its nursing staff and injections would not be a part of the Medication Technicians job description as they were not medical professionals. Most residents transitioned into oral medications or had outside agencies oversee their insulin medications. S1 mentioned few residents opted to move to other facilities. An interview with the Long-Term Care Ombudsman (LTCO) reviewed former notes which showed LTCO made a site visit on February 7, 2022, with no remarkable notes. LTCO received information regarding a notification sent to families for persons who need assistance with insulin care, but no additional information was entered. A letter from Pacifica Senior Living, dated February 9, 2022, said “Effective 4/09/2022 Pacifica Vista will be discontinuing our Diabetic Management program due to the Nationwide Nursing shortage.” The letter had information to contact Michael McCoy or their Regional Director of Operations with questions or concerns. According to R1s Admission Agreement, dated February 13, 2019, the facility assisted with medication management. According to R1s medication administration record, dated February 2022, it demonstrated that the primary care physician’s order indicated the units to be increased or decreased to be used depending on R1s sugar levels at bedtime. R1 was provided with their routine insulin pen to be used before meals. Physician’s Report (LIC602) dated March 10, 2021, R1 was diagnosed with cognitive impairment and was deemed unable to manage their own medications. According to the R1s assessment, dated July 15, 2020, and September 15, 2021, they were categorized as level 5 and required total medication assistance. R1 Needs and Service Plan, dated September 15, 2021, and July 15, 2020, showed R1 had a diabetic diet and needed total assistance with medications. Additional records revealed that R1s LIC 602, dated May 12, 2023, was updated to include their medications and their orders. R1s MAR, dated August 2022, said that they were taking their blood sugar medication orally. According to the Facility’s Death Report, R1 passed at the facility on September 18, 2023, where R1 received hospice services. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside source interviews and records reviewed, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Angeles Frasier, Resident Service Coordinator. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to Resident Service Coordinator Frasier at the conclusion of the visit. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, Feb 26, 2025 · control 08-AS-20220215090659

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that one-hundred and eight (108) clients live at this facility. There was twenty-eight (28) staff members present. The Business Office Manager, Jhonalyn Libunao and The Resident Services Director, Esmeralda Reyes conducted the facility tour. The Executive Director, Mike McCoy completed the facility tour. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Ten (10) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration: LPA reviewed employee records. Ten (10) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Michael D McCoy’s Administrator’s certificate expiration date is 08/08/2024. Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a location for sharps in the kitchen. Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 75 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 107.0 degrees F. Laundry is done in the designated laundry room located on the 2nd floor of building B. There is a locked closet for storing laundry soap and other chemicals in the housekeeper’s closet on the 2nd floor. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA dialed the facility’s landline number, which rang and was operable. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There are no fireplaces at this facility. There are no pools at the facility. LPA observed emergency supplies and first aid kits. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training. Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA reviewed ten (10) random residents’ medication logs and observed that they were logged and dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed smoke detectors and carbon monoxide detectors throughout the facility. The facility alarms are hardwired throughout the facility and monitored by Dialcom System Group, 24 hours a day. The City of Vista Fire Department granted Pacifica Senior Living a fire department permit on 06/19/2023. There were fifty-four (54) fire extinguishers on site, last recharged date 01/08/2024. Pursuant to the Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to the Executive Director, Mike McCoy.the state’s words, verbatim · CDSS document, Apr 3, 2024

Allegation investigated: - Licensee is not allowing resident access to telephone. - Licensee is not allowing resident to receive visitors.

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA identified herself and was granted entry by Executive Director Michael McCoy. LPA stated the purpose of the visit and reviewed the findings of the complaint with Memory Care Director Starsha Clark. The Department’s investigation consisted of interviews with staff and outside sources, records review of relevant documents pertinent to this investigation, and LPA observations. On August 12, 2021, it was alleged that the facility did not allow resident access to a telephone, and the facility did not allow resident to receive visitors. It was alleged that the facility did not allow the resident #1 (R1) to communicate with their visitors via telephone and did not make other attempts to contact R1 via facility telephone during this time. According to RP the resident was sleeping when they made the attempt to contact R1. (Continuation on LIC9099-C) Unsubstantiated According to the former Executive Director, R1 was able to receive their phone calls in the reception area. Callers would need to call the facility and they transfer the call to the area where the resident resides. In review of the resident’s records R1 does get confused and forgetful. According to the facility’s basic services the facility does not provide a phone to the resident but when requested the Community would make reasonable access to a telephone for local calls. In review of R1’s Admission Agreement, families/residents are responsible for the telephone and the connection to their preferred company. During a visit on 09/08/2021, LPA observed that the resident had a cell phone charger plugged in to the wall and a note with the cell phone number and said the property belonged to the R1s friend and to return the property to R1. Although the charger was present the cell phone was nowhere in sight. According to an interview with R1 their POA had removed their cell phone device. Based on the information obtained there is insufficient evidence to support the allegation. It was alleged that the facility is not allowing Resident #1 (R1) to receive their visitors. During an interview with the former Executive Director, they mentioned that R1’s power of attorney (POA) had requested R1 not to have visitors as they wanted R1 to adjust to their new surroundings. ED said that visitors had contacted a lawyer to sue their POA but R1 was unaware that they were doing so. Interviews with staff confirmed that they did refuse R1 to have their visitors enter into the community to visit with them. Staff confirmed that they proceeded with the refusal of visitors at the direction of R1’s POA. According to staff interviews there were a total of three visitors who were refused visits with R1. Interview with R1 confirmed that they recognized who two of three visitors were. In review of a self-reported incident report (IR) submitted to the San Diego Regional Office (SDRO), it said that one of R1s visitors was making R1 upset for issues that were beyond R1s control. This caused R1 to want to leave the facility and staff were unable to redirect R1. The visitor raised their voice to R1 and then told R1 that they should “bust through the doors.” Staff were able to contact R1s POA who reassured R1 everything was fine. At this time, the staff was able to redirect R1 and management requested to speak with R1s visitor outside. Staff were able to contact local law enforcement who recommended that staff not allow visitor to return to the community. If the visitor returned, they recommended the facility to call law enforcement again. According to the Physician’s Report, R1 is unable to leave the facility unassisted and is cognitively impaired. Records show that R1 does have an assigned power of attorney (POA) who is able to make their decisions for them. Based on the letters from R1’s primary care physicians which said that R1 met the criteria for neurocognitive disorder and lacked the capacity to make decisions, as such court orders had assigned R1 POA’s. Due to R1s cognitive state of mind, visits could be set-up during times when R1s family was at the facility. Based on the information obtained there is not sufficient evidence to support the allegation. (Continuation on LIC9099-C) (Continuation of LIC9099-C) Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and outside source interviews and records reviewed, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Executive Director Michael McCoy and Memory Care Director Starsha Clark. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to Executive Director Michael McCoy at the conclusion of the visit. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, Mar 13, 2024 · control 08-AS-20210812164031

Allegation investigated: - Staff are not allowing resident to leave the facility.

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by Executive Director Michael McCoy. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director Michael McCoy and Memory Care Director Starsha Clark. The Department’s investigation consisted of interviews with staff and outside sources, and records review of relevant documents pertinent to this investigation. On September 2, 2021, it was specifically alleged that the facility did not allow the resident to leave the facility to conduct his daily activities with them or other acquaintances. (Continuation on LIC9099-C) Unsubstantiated (Continuation of LIC9099) It was specifically alleged that the facility did not allow resident #1 (R1) to leave the facility. According to the residents Physician’s Report (LIC602), R1 had cognitive impairment and was unable to leave the facility unassisted. Per LIC602, R1’s mental condition was confused and disoriented. Letters from R1’s primary care physicians say that R1 met the criteria for neurocognitive disorder and lacked the capacity to make decisions such as medical and financial decisions and would benefit from having a fiduciary. According to court documents, R1 had been assigned power of attorney’s (POA) for medical and financial decisions. The facility had submitted an incident report to the Department indicating that the Sherriff’s Department was contacted as a visitor was making R1 uneasy and anxious and wanted to take R1 out of the facility. According to the report, the Sherriff’s Department recommended contacting them if that visitor attempted to return. According to the former Executive Director, the facility was ensuring safety measures for R1 were met. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside sources interviews and records reviewed, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Executive Director, Michael McCoy and Memory Care Director Starsha Clark, to whom a copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided at the conclusion of the visit. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, Mar 13, 2024 · control 08-AS-20210902145842

Allegation investigated: - Facility staff neglected to assist residents with incontinence care - Facility staff neglected to keep residents room clean from odors

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA identified herself and was granted entry by Jonalyn Libunao, Business Office Manager. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director (ED) Michael McCoy,and Esmeralda Reyes, Resident Service Director (RSD). The Department’s investigation consisted of interviews with staff and outside sources, records review of relevant documents pertinent to this investigation. On November 25, 2020, it was alleged that the facility staff neglected to assist residents with incontinence care; and facility staff neglected to keep residents’ room free from odors. It was specifically alleged that resident #1 (R1) was not changed throughout the night and had dried fecal matter stuck to their skin. Interviews with former and current staff said that they did not have any issues with changing residents. They were short staffed, but they managed to check their assigned residents when needed, which would be about every 2 hours. Unsubstantiated If they were wet, they would be changed. According to a former staff member, they would be assigned approximately 20 to 30 residents, but they checked if changing was needed. They mentioned that there may have been times where other staff may not have changed all their residents, but they never witnessed, nor did they miss in changing their assigned residents. Staff and former staff did say that there were residents who would either refuse or give staff difficulties changing them. When this occurred, staff would switch resident checks to observe if another staff member would be able to assist with those who refused or had difficulties with. No staff reported issues with other shifts not keeping up with their checks. Former and current staff reported working well with their co-workers. In review of the facility documents, it was noted that the resident had a loss of cognitive functioning and needed one-person standby assistance for toileting needs. Documents show that the facility needed to assist the resident in the bathroom every two hours for toileting assistance. According to the facility service plan, it annotated that incontinence care or toileting service while resident is awake; if the resident refused, they would need to inform nurse on duty and or the RSD; also, if resident refused care to a care staff, they would try change of staff face technique. It was noted that the resident was able to shower self and noted that at times R1 refused to be showered by their third-party agency. The facility did have incontinence checks logs for R1 the months of August 2020 and September 2020 only. According to records, staff would change the R1 between 6:30 AM – 7:30 AM; with mainly staying within the range assisting the resident in the morning with incontinence care at about 7:00 AM. The facility staff incontinence checks ranged daily between 28 minutes to about 3 hours but staying within the range of checking R1 every 2 hours between the hours of around 7 AM until about 10 PM. Incontinence checks indicated if the resident needed to be changed or was dried at the time of the check. Based on the information obtained during interviews and records reviewed, there is insufficient evidence to support the allegation. It was specifically alleged that due to staff not changing R1 throughout the night, R1’s entire room was malodorous when they opened their door. Staff and former staff interviewed did not raise concerns regarding residents not being changed during their assigned shifts. If staff did not have issues with residents being changed, there would be no indication that there were residents who had a malodorous room due to staff not checking residents’ incontinence care. Based on the evidence obtained during the investigation, there is insufficient evidence to support the allegation. Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and outside sources interviews and records reviewed, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Executive Director McCoy, and Resident Service Director Reyes. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to ED McCoy at the conclusion of the visit. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, Jan 31, 2024 · control 08-AS-20201125155602

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced visit to deliver findings for a complaint investigation and in conjunction conduct this case management visit regarding the residents rights. LPA identified herself and was granted entry by Jonalyn Libunao, Business Office Manager. LPA stated the purpose of the visit and reviewed the elements of the case management visit with Executive Director Michael McCoy, and Esmeralda Reyes, Resident Service Director (RSD). The Department’s investigation regarding the complaint dated December 7, 2020, control number 08-AS-20201125155602, resulted in unsubstantiated findings, but a discrepancy was observed during the review of resident records. Based on the Needs and Service Plan for resident #1 (R1 – see LIC811 Confidential Names list), dated 08/17/2020, the plan was incomplete and did not have R1 or their responsible party’s signature. It should also be noted that the Authorized Community Representative signature was not on the updated plan as well. During today’s visit, LPA reviewed Title 22, Division 6, Chapter 8, Sections 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities, specifically section (a)(7). Based on the Department’s investigation and the evidence obtained during records review, deficiencies are cited during this case management visit and can be viewed on the LIC809-D page of this report. The report was discussed, a plan of correction was jointly developed, and an exit interview was conducted with Executive Director McCoy, and Resident Service Director Reyes. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to ED McCoy at the conclusion of the visit. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, Jan 31, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2 · Plan of correction due date: Feb 16, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(7) To fully participate in planning their care, including the right to attend and participate in meetings or communications regarding care and services to be provided, according to Health and Safety Code section 1569.80 and involve persons of their choice in this planning. The licensee shall provide necessary information and support to ensure that residents direct the planning of their care to the maximum extent possible, and are enabled to make informed decisions and choices… this requirement was not met as evidenced by: Based on LPA’s records review, the Facility did not ensure that the resident or their representative were updated in the resident’s care plan which poses a potential personal rights risk to 1 [R1] of 127 residents in care.the state’s words, verbatim · CDSS document, Jan 31, 2024

Plan of correction: Facility will be conducting staff training for resident service plans and submit the training documents for staff ED, RSD, MCD, and RCC to be provided training. Documents will be submitted to LPA by POC due date, 02/16/2024.

Allegation investigated: Staff do not ensure resident’s room is clean and sanitary Resident’s room is malodorous

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to the facility to initiate an investigation regarding the allegations listed above. LPA was granted entry and met with Memory Care Director Starsha Clark who was informed of the purpose for this visit. LPA toured the facility, reviewed records, conducted interviews, and took copies of pertinent information. Regarding the allegation "Staff do not ensure resident’s room is clean and sanitary” and "Resident’s room is malodorous", LPA conducted interviews with staff, residents, and Resident One (R1) that does not corroborate with the allegations. LPA’s initial walkthrough of the facility was conducted and revealed room #406, #409, #411, #412, and #416 and their attached bathrooms to be clean and in good repair. LPA's observations during the tour of the facility revealed the residents’ rooms are clean and organized, no observable dirty clothes on any of the floors, and there were no strong orders of any kind present. (Continued on LIC 9099-C) Unsubstantiated Additional feedback provided during interviews with staff and residents revealed that caregivers make the residents’ bed and clean the residents’ room daily. Based on observation and interviews, there is no concerns that would prove that the facility is dirty or malodorous thus the allegations are UNSUBSTANTIATED. An allegation(s) finding of unsubstantiated means, although the allegations may have happened or are valid, there is not a preponderance of the evidence strand to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of this report was provided to Starsha Clark.the state’s words, verbatim · CDSS document, Oct 26, 2023 · control 18-AS-20231025125859

Type of visit: Case Management - Other

On September 29, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to the facility to conduct a Health and Safety Visit and met with the Administrator Mike McCoy. LPA Mixson toured the facility along with the Administrator. LPA Mixson observed facility clean, neat, and well organized. The utilities were observed to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide assistance to the residents as needed. LPA Mixson assessed the available food supply and observed the supply exceeds the requirement of a two day supply of perishable foods and a seven day supply of non-perishable foods. Medications were found to be in sufficient supply and locked on med carts and in the med room. There were no Health and/or Safety concerns observed while conducting the tour of the facility at this time. The facility had the required Regulation postings. The LPA observed an activities schedule, the resident council minutes and schedule of the next meetings. LPA Mixson observed the environment was positive and the residents were welcoming and greeting staff and visitor who arrived. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and/or the welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to the Administrator Mike McCoy.the state’s words, verbatim · CDSS document, Sep 29, 2023