Redwood Senior Living Bakersfield

Allegation investigated: Staff did not provide resident's records to resident Staff does not allow resident access to their belongings Staff do not ensure resident's room is clean and sanitary

On 6/30/26 at 5:00 pm Licensing Program Analyst (LPA) J. Leffall conducted an initial complaint visit to open and to deliver findings on above allegations. LPA met with Adminstrator (A1) Beatriz Ponce. The Department conducted interviews with staff, and obtained records. LPA attempted to contact RP. RP was not available. LPA left a message via voicemail. RP did not return LPA's call. LPA requested to interview R1 at faclilty. R1 was voluntarily dischared as of 6/2/26. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is Unsubstantiated. No deficiencies were issued. Exit interview conducted. A copy of this report was distributed to Administrator which confirms signature of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 30, 2026 · control 24-AS-20260625154317

Type of visit: Required - 1 Year

On 6/30/26, Licensing Program Analyst (LPA) J. Leffall arrived at the facility unannounced to conduct the Required Annual Inspection. LPA met with Administrator Beatriz Ponce, Licensee (L1) Anthony Barbato, and Regional Director (RD) Steven Cruz. LPA explained the purpose of the inspection and was granted entry into the facility by the Med Tech (MT) Barbara Martin. A tour of the facility was conducted with A1. The residence was set at 72 F temperature and free of passageway obstructions inside and outside. Kitchen toured, LPA observed 2 day supply of perishable food and 7 day supply of non-perishable food. Kitchen was clean and organized. Sharps and knives are kept locked in kitchen cabinet. Cleaning supplies were in a locked closet smoke detectors and carbon monoxide detectors were checked and operating. Water temperature measured within regulatory range. Tel-Tec Security Systems conducts a Fire Alarm system inspection annually. Facility has a fire sprinkler system. Fire extinguishers last inspected 8/7/25 and pressure gauges are in the good range. LPA with A1 inspected the backyard. LPA, observed that the backyard is well maintained, trees and grass in good condition. Patio furniture is clean and ready for use. LPA observed two locked sheds. Sheds store extra equipment, incontinence pads/diapers, emergency supply of water (4 five gallon water jugs). The exterior walkways are free from obstructions and debris. There are four patio tables with umbrellas and seating. LPA met with med tech and conducted audit of pill count and MARS documentation. Records were up to date and in full compliance. Medication room is locked and med carts locked within that room. LPA observed medications are stored in medication room. Medication bins for each resident, labeled and organized. First aid kit was inspected and found to contain the required items. Report continued on LIC-809C........ During today's inspection, LPA observed 3 resident bedrooms. Bedrooms contained 2 residents each. The bedrooms were well lit. Window and screens are in good condition. Bedrooms have two twin beds, ample space between the beds, a shared dresser, two night stands, and a shared closet that can store the residents' personal belongings. Furniture and linens are free from stains and are well maintained. The resident rooms are set up with a jack-and-jill bathroom between them, shared between 2 rooms. Water tested at a range of 111.3 to 113.9 degrees F in 3 bathrooms. Smoke detector and carbon monoxide tested to be operational. Fire drill conducted on 5/19/26. No deficiencies issued during inspection. Exit Interview conducted. LPA is requesting the following documents be submitted to the Fresno CCL office by 5/29/26: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance-RCFE, Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A) A copy of this report was provided to Administrator, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Jun 30, 2026

Type of visit: Case Management - Health Checks

On 6/22/2026, Licensing Program Analyst (LPA) M Vega arrived unannounced at the facility to conduct a case management follow up visit, LPA was granted entry into the facility by staff. LPA met with Regional Director - Steven Cruz and Managing Member of Redwood Bakersfield LLC - Anthony Barbedo and explained the reason for today’s visit. LPA conducted a Health & Safety case management visit to obtain information regarding a death report which had been submitted by the facility as required. The Department has reviewed the information obtained. A copy of R1 complete facility file was requested by LPA from facility. LPA conducted a walk through of facility, some residents were in common living space, others in their rooms. There were no violations identified during visit. No citations issued. An exit interview was conducted with Regional Director. A copy of this signed report was provided to Regional Director for facility records.the state’s words, verbatim · CDSS document, Jun 22, 2026

Allegation investigated: Staff do not ensure that outside vendors maintain resident privacy during the provision of services.

Licensing Program Analyst (LPA) K. Kaur arrived at the facility for initial 10-day complaint inspection. LPA met with Administrator Beatriz Ponce and explained the purpose of the visit and reviewed the elements of the allegations. LPA delivered the following complaint investigation findings. The Department investigated the allegations listed above. Based on observations, interviews conducted and records reviewed, the facility hired an entertainment vendor that posted residents videos on social media networks which violates resident privacy during the provision of these services. The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. See citations on the attached LIC9099D. Exit interview was conducted with Administrator, a copy of this report and appeal rights were discussed and provided to Administrator, whose signature on this form confirms receipt of this document Substantiatedthe state’s words, verbatim · CDSS document, Apr 17, 2026 · control 24-AS-20260416095945

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Apr 18, 2026

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: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement was not met as evidenced: Based on interviews, records reviewed, and videos, resident personal privacy was violated.the state’s words, verbatim · CDSS document, Apr 17, 2026

Plan of correction: Administrator/ Licensee agrees to review personal rights and provide training to staff and submit documentation when completed to ensure residents personal rights are not violated in a similar manner.

Allegation investigated: Staff not following needs and services Resident lost weight due to a lack of care and supervision

Licensing Program Analyst (LPA) K. Kaur arrived at the facility for a subsequent visit. LPA was allowed entry by staff. LPA met with Administrator Beatriz Ponce and explained the purpose of the visit and reviewed the elements of the allegations. LPA delivered the following complaint investigation findings. The Department investigated the allegations listed above. Based on interviews conducted and records reviewed, the resident (R1) is being prompted for meals. Residents are taken to dining area; and/if residents miss a meal due to nap; residents’ plate is saved. The facility also has an open menu available at all times to order food outside of meals and snacks. Based on staff interviews, residents’ needs and service plan is being followed. Based on observation and interviews of staff and residents, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur, therefore these allegations are unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 27, 2026 · control 24-AS-20260121095216

Allegation investigated: Staff did not provide adequate care and supervision resulting in resident losing weight Staff did not meet resident’s dental care needs Staff did not safeguard resident's personal belongings Resident sustained multiple bruises due to staff neglect or physical abuse

On 03/25/2026, Licensing Program Analyst (LPA) J. Duarte arrived unannounced to commence a complaint investigation. LPA introduced self, stated the purpose of the visit and met with Administrator Beatriz Ponce. The Department conducted interviews and reviewed records. Based on the interviews conducted, observations, and records reviewed, the facility provides care and supervision to R1, R1 is taken to doctor appointments by POA or staff transport R1 to appointments, the items listed on R1's personal property and valuables were observed in R1's room, and LPA did not observe any bruises on R1. 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, therefore the allegations are Unsubstantiated. An exit interview was conducted. A copy of this report was provided to Administrator Beatriz Ponce, whose signature confirms receipt of this document. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 25, 2026 · control 24-AS-20260316121350

Allegation investigated: Staff does not ensure facility is free of bed bugs/pests.

On 03/12/2026, an unannounced Complaint visit was conducted by Licensing Program Analyst (LPA) J. Duarte and Licensing Program Manager (LPM) S. Doucette. LPA and LPM met with Administrator Beatrice Ponce. LPA and LPM introduced selves and stated purpose of visit. During the course of the investigation, LPA conducted interviews, received copies of records, and toured the facility. The administrator stated she was notified on Tuesday, 03/10/2026, that there was a resident room that had bed bugs, and pests control was contacted on the same date to service the room for bed bugs. The facility has a service agreement with a pest crontrol company that provides service once a month for preventitive measures. In addition, another pest control company was on site at the facility during today's visit, servicing the resident room that was reported to have bed bugs. The pest control company that was on site reported that bed bugs were not observed in any other parts of the facility. The Regional Director stated that the facility will follow pests control recommendations and submit a preventitive plan to CCLD. Continued on LIC9099-C Unsubstantiated Continued from LIC9099. Resident and staff interviews also revealed the facility addressed the pests issue promptly. Therefore, the allegation, staff does not ensure facility is free of bed bugs/pests, 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. An exit interview was conducted, and a copy of the report was provided to Administrator Beatriz Ponce.the state’s words, verbatim · CDSS document, Mar 12, 2026 · control 24-AS-20260310164710

Allegation investigated: Staff not assisting residents with their care needs Staff are violating residents' personal rights

On 02/11/2026 Licensing Program Analyst (LPA) M Vega arrived at the facility for an unannounced initial complaint visit. LPA met with facility staff, explained reason for visit and was permitted entry into the facility. LPA met with Administrator - Brandon Weber and Regional Director - Steven Cruz. During visit LPA requested the following documentation (LIC 9020 - Register of Facility Clients, LIC 500 - Staff Roster, and LIC 602A, 603 and 625) Health and satey tour conducted at facility. During investigation documentation was requested and reviewed and interviews were conducted. Staff/(s) does not work at the facility per staff interview and documents obtained. The allegations are UNFOUNDED, meaning the allegations are false, could not have happened, and/or is without a reasonable basis. Nothe state’s words, verbatim · CDSS document, Feb 11, 2026 · control 24-AS-20260206072155

Allegation investigated: Staff is manipulating resident. Staff is rejecting care services for resident.

On 10/30/2025 Licensing Program Analysts (LPA) B. Miranda conducted an unannounced complaint visit and was granted entry. LPA met with Administrator Beatriz Ponce. LPA explained the purpose of the visit. LPA conducted interviews and reviewed records regarding the allegations listed above. R1 is not conserved and is able to make their own choices. LPA observed R1 at the facility. Administrator stated R1 was being rehabilitated at Visalia Post Acute and returned to the Redwood Senior Living facility on 10/29/2025. Administrator stated the social worker from Visalia Post Acute contacted the facility to inform R1 wanted to return to facility and had completed their rehabilitation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation are UNSUBSTANTIATED. Exit interview was conducted and a copy of this report LIC9099 was provided to Administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 30, 2025 · control 24-AS-20251004150959

Type of visit: Case Management - Other

This report has been AMENDED from the Original Report. On 10/30/2025 Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct a case management visit. LPA was allowed entrance into the facility by staff. During todays visit LPA observed the same double dead-bolt on the outside gate and knock box. LPA asked how many dementia residents were at the facility and Administrator stated about 15. LPA showed Administrator current fire clearance on file which does not indicate a double dead-bolt or knock box. Fire Clearance on file was cleared on 4/1/2021. LPA observed R1's Admission Agreement which has Addendum E with a revised date of 6/17/2024 due to having outside perimeter locked. The revised Addendum comes after the fire clearance was cleared. Administrator provided verification of Fire Inspection completed on 4/15/2025, which indicates a knock box needs to be installed. Administrator stated the fire department stated the knock box needs to be installed so the fire department can access the facility in case of an emergency. This is conflicting due to the fire department not previous having access from 4/1/2021-4/15/2025. This means fire clearance is not being maintained with. LPA also observed a staff's car to be double parked while working and caring for residents, which can cause a dangerous obstruction. Deficiency will be cited under Title 22. Civil penalty will be issued. When changes are made to the current fire clearance on file, there is proper paperwork to be filed with licensing so the updated fire clearance can be on file. Licensee did not file the proper paperwork to update fire clearance. Due to facility failing to properly notify licensing and file proper paperwork. Deficiency will be cited under Title 22. Exit interview was conducted and a copy of this report LIC809, LIC809D, appeal rights, and civil penalty were provided to Administrator.the state’s words, verbatim · CDSS document, Oct 30, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Oct 31, 2025

87705 Care of Persons with Dementia (f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or perimeter fence gates and that facility staff on all shifts have access to, and know how to use, equipment needed to unlock exterior doors or perimeter fence gates. This requirement is not met as evidenced by: Based on observation, interviews, and record review, the licensee failed to report changes to the fire clearance, which poses an immediate Health, Safety, or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: Licensee/Administrator will submit the proper paperwork to have the current fire clearance updated with licensing.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(f)(1) · Plan of correction due date: Nov 7, 2025

87705 Care of Persons with Dementia (f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: (1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates. Based on observation, interviews, and record review, the licensee failed to report update to fire clearance indicating there was a knockbox added, this poses a potential Health, Safety, or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: Licensee/Administrator will submit the proper paperwork to have the current fire clearance updated with licensing.

Type of visit: Case Management - Other

On 10/8/2025 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct a case management. Upon arrival LPA observed R3 between the poles of the iron fence at the facility. S1 & S2 were both with R3 attempting to redirect R3. LPA asked if R3 was stuck in the fence, staff stated no they are trying to leave the facility. LPA asked what triggers the fence to open, staff stated it is opened from inside. LPA explained this is dangerous due to the fence opening towards the resident and could potentially pin the resident between the fence. There is another opening in the gate to walk through, but this part of the gate has a double dead bolt lock and can only be opened with a key. LPA obtained copies of R3's physical, reappraisal, and appraisal forms. Licensee Anthony will provide LPA with copy of approved fire clearance by 10/13/2025. Follow-up visit will be warranted if citation are to be issued at a later time once all documentation is reviewed. Exit interview was conducted and a copy of this report LIC809 was provided at Licensee Anthony Barbato.the state’s words, verbatim · CDSS document, Oct 8, 2025

Type of visit: Required - 1 Year

On June 5, 2025, Licensing Program Analyst (LPA) Rachel Bruce arrived at the facility unannounced to conduct the Required Annual Inspection. LPA met with Administrator Beatriz Ponce and Assistant Administrator Sabrina Arnelas. LPA explained the purpose of the inspection and was granted entry into the facility by the Med Tech, Barbara Martin. A tour of the facility was conducted with the Med Tech and Assistant Administrator. The residence was set at 72 F temperature and free of passageway obstructions inside and outside. Kitchen toured, LPA observed 2 day supply of perishable food and 7 day supply of non-perishable food. Kitchen was clean and organized. Sharps and knives are kept locked in kitchen cabinet. Cleaning supplies were in a locked closet smoke detectors and carbon monoxide detectors were checked and operating. Water temperature measured within regulatory range. Tel-Tec Security Systems conducts a Fire Alarm system inspection annually. Facility has a fire sprinkler system. Fire extinguishers last inspected on August 2024 and pressure gauges are in the good range. LPA with AD inspected the backyard. LPA, observed that the backyard is well maintained, trees and grass in good condition. Patio furniture is clean and ready for use. LPA observed two locked sheds. Sheds store extra equipment, incontinence pads/diapers, emergency supply of water (4 five gallon water jugs). The exterior walkways are free from obstructions and debris. There are four patio tables with umbrellas and seating. Status of the fence and repairs will be determined at the next visit. LPA met with med tech and conducted audit of pill count and MARS documentation. Records were up to date and in full compliance. Medication room is locked and med carts locked within that room. LPA observed medications are stored in medication room. Medication bins for each resident, labeled and organized. First aid kit was inspected and found to contain the required items. During today's inspection, LPA observed 7 resident bedrooms. The bedrooms were well lit. Window and screens are in good condition. Bedrooms have two twin beds, ample space between the beds, a shared dresser, two night stands, and a shared closet that can store the residents' personal belongings. Furniture and linens are free from stains and are well maintained. The resident rooms are set up with a jack-and-jill bathroom between them - shared between 2 rooms. Water tested at 98 in one random bathroom and 103.2 in another. All bathrooms inspected today were in need of paint. Patching repair had been completed but need to be painted. LPA observed Staff Room to be clean and organized. Due to time restraints, LPA will return to complete inspection and issue any citations necessary. At that visit, physical inspection will be reviewed and any incomplete issues will be resolved. LPA will also review staff and resident files and conduct interviews with both staff and residents. LPA will also utilize the Care Tools system to complete the Required Annual Inspection. An exit interview was conducted and a copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Jun 5, 2025

Allegation investigated: Licensee did not provide adequate food services to residents.

On January 31, 2025, Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced complaint investigation visit to the facility. During this visit LPA delivered the investigation finding regarding the above allegation. The Department has investigated the complaint alleging that the facility did not provide adequate food service. Based on the interviews conducted of both staff and residents, the above allegation is deemed to be UNSUBSTANTIATED. LPA recieved conflicting information but determined that regardless of what may have been alleged, the residents are provided alternative menu options and appropriate efforts are made to accomodate the resident's prefrences. Although the allegation may have happened or may be 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 copyt of this report will be provided to the Administrator via email. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 31, 2025 · control 24-AS-20250127142900

Allegation investigated: Regarding the allegation Facility staff did not provide resident medication as prescribed. Regarding the allegation Facility staff did not safeguard resident’s belongings

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility to deliver findings on the allegations above. LPA met with facility Licensee, Anthony Barbato and explained the purpose of today's visit. Regarding the allegation Facility staff did not provide resident medication as prescribed. Resident 1 is receiving medications as prescribed. Resident 1 stated they were hiding a medication in their bedroom. Staff discovered the medication and began giving to Resident 1 when they received the doctors orders including instructions from the Physician. 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. Continued.. Unsubstantiated Continued... Regarding the allegation Facility staff did not safeguard resident’s belongings. Resident 1 stated the facility staff assisted them with cleaning out their room as it was very cluttered. Resident 1 stated they noticed some items missing from the room shortly after the staff assisted with clean up. Licensee stated Resident 1's room was so cluttered it was a hazard, and he offered the staff to assist with cleaning out the room. Facility Licensee stated he is confident the facility staff only removed items agreed upon when cleaning out the clutter from Resident 1's room. 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. Exit interview conducted with Licensee, Anthony Barbato, and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 28, 2024 · control 24-AS-20240826115957

Allegation investigated: Staff does not ensure medications are properly managed for resident in care Staff do not speak in an appropriate manner to resident in care

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility to deliver findings on the allegations above. LPA met with facility Licensee, Anthony Barbato and explained the purpose of today's visit. Regarding the allegation Staff does not ensure medications are properly managed for resident in care. Resident 1 is receiving medications as prescribed. Resident 1 stated they were hiding a medication in their bedroom. Staff discovered the hidden medication and began giving to Resident 1 when they received the doctors orders including instructions from the Physician. 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. Unsubstantiated Regarding the allegation Staff do not speak in an appropriate manner to resident in care. Resident 1 stated facility Administrator has spoken to them rudely on several occasions. Facility Administrator stated she has not ever and would never speak rudely to any facility Residents. Licensing staff interviewed several facility residents who all stated they are never spoken to rude, and are treated very well by facility staff. 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. Exit interview conducted with Licensee, Anthony Barbato , and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 28, 2024 · control 24-AS-20240828153738

Allegation investigated: Staff do not provide adequate food service Staff did not prevent the residents from fighting while in care Staff behavior poses as a risk to the residents

On October 24, 2024, Licensing Program Analyst (LPA) Rachel Bruce arrived at Redwood Senior Living Bakersfield for the purpose of delivering findings on the above allegations. During the course of this investigation LPA L. Padgett began by reviewing facility files relevant to the complaint investigation and interviewing both staff and residents. The file was transferred to LPA Bruce in October, 2024 and LPA Bruce reviewed the acquired documentation, toured the facility and conducted one staff interview. Based on the investigation in total, it has been determined that the above allegations are UNFOUNDED. 1) Staff do not provide adquate food service is referring to residents who signed up for the food bank senior box to be delivered. Investigation revealed this was totally optional and was in addition to the food already provided. 2) Staff do not prevent residents from fighting. Interviews revealed that Residents can and sometimes do exhibit behavior that requires intervention which staff does appropriately. 3) Staff behavior poses a risk to the residents was referencing an inquiry from one resident about another resident's money. Staff that handles Resident financial matters replied that the resident would have to wait for the money to be available. There is a system in place to deliver and account for money per regulation. Unfounded This agency has investigated the complaint and found the allegations to be UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis, therefore we have dismissed the complaint. Exit interview conducted. A copy of this report was discussed and will be provided via email to Administrator Beatriz Ponce.the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 24-AS-20240505222013

Type of visit: Case Management - Incident

On October 24, 2024, Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced case management inspection to discuss Care and Supervision. On September 9,2024, Community Care Licensing (CCL) received an incident report regarding two clients who had an altercation. One resident who thought another resident was not letting him pass in the hallway reacted by hitting him. This was witnessed by staff who stepped in and separated the clients. She observed there were no injuries and appropriately notified the necessary staff and also alerted the Sheriff Department and CCL. Discussion was had regarding the appropriate response and to remind the staff to be vigilant in watching the client interaction and to take action when needed. Staff have been notified to speak with the residents, separate them and call appropriate parties if necessary. LPA interviewed 4 residents who all stated that the staff is very effective in their duties and handle resident issues or disputes in a quick and appropriate manner.the state’s words, verbatim · CDSS document, Oct 24, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst L. Padgett (LPA), conducted an unannounced annual continuation visit (visit started on 5/31/2024) to the facility and met with Administrator Beatriz Ponce (AD) and Regional Director Steven Cruz. LPA stated the purpose of the visit and was accompanied by AD while conducting the inspection of the facility. At the time of the visit, LPA observed residents in the facility. LPA observed that the kitchen was well maintained, with working lights and well maintained appliances. The knives were kept in a locked drawer not easily accessible. The kitchen counters and sink are free from debris. LPA observed a trash bin with the lid. LPA observed that refrigerator, was kept at a 42 degree F, well maintained and clean. LPA observed a 2 day perishable food supply. The kitchen pantry was clean, organized and had 7 days of non-perishable food. No expired food was observed. LPA observed the dining room with 4 tables is well lit. Dining has seating for 16 and is clean and in good condition. LPA observed the living room has no fireplace. Television was observed to be in a secure place, the living room floor has carpet in good condition. LPA observed sofas and recliners to be in good condition. In the hallway that leads to the bedrooms, LPA observed, smoke detector and carbon monoxide detectors installed. The smoke alarm and carbon monoxide detectors were tested by AD and are functioning Fire extinguishers are mounted on the walls and inspected on 5/1/2024 with the pressure gauge in good range as indicated on the meter. continued on the LIC809-C LPA observed 7 resident bedrooms. The bedrooms well lit. Window and screens are in good condition. Bedrooms have two twin beds, ample space between the beds, a shared dresser, two night stands, a shared closet that can store the residents' personal belongings. Furniture and linens are free from stain and are well maintained. LPA with AD inspected the backyard. LPA, observed that the backyard is well maintained, trees and grass in good condition. Patio furniture is clean and ready for use. LPA observed two locked sheds. Sheds store extra equipment, incontinence pads/diapers, emergency supply of water (4 five gallon water jugs). The exterior walkways are free from obstructions and debris. LPA observed Staff Room to be clean and organized. LPA observed medications are stored in medication room. Medication bins for each resident, labeled and organized. First aid kit was inspected and found to contain the required items. LPA reviewed residents and staff records with AD and found that training documents are in not up to date. Deficiencies were cited during today's visit per California Code of Regulations (CCR) Title 22. An exit interview was conducted with AD. A copy of the signed report and appeals rights were provided. LPA is requesting the following documents be submitted to the Fresno CCL office by 6/21/2024, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610D) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.the state’s words, verbatim · CDSS document, Jun 13, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst L. Padgett arrived at the facility unannounced to conduct the Required Annual Inspection. LPA's met with Administrator Beatriz Ponce and Regional Director Steven Cruz. LPA explained the purpose of the inspection and was granted entry into the facility by the Med Tech. A tour of the facility was conducted with the Administrator. The residence was set at 72 F temperature and free of passageway obstructions inside and outside. Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked Medication room. Cleaning supplies were in a locked closet. Smoke detectors and carbon monoxide detectors were checked and operating. Tel-Tec Security Systems conducted a Fire Alarm system inspection on 5/7/2024. Facility has a fire sprinkler system. Fire extinguishers last inspected on 05/01/24, pressure gauge is in the good range. Outdoors there are four patio tables with umbrellas and seating. LPA observed that the backyard is well maintained, trees and grass in good condition. Resident, medication and staff records were reviewed. LPA reviewed staff and Resident files. Due to time constraints deficiencies are listed below and citations will be issued at a later date. LPA will return to the facility at a later date. An exit interview was conducted and a copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, May 31, 2024

Allegation investigated: Staff is disclosing personal information about a resident.

Licensing Program Analyst (LPA) Lissett Padgett conducted the subsequent complaint investigation visit to the facility. During the course of this complaint investigation LPA interviewed staff on duty and reviewed facility records. It was determined based on the interviews and records review and this LPA's observations, that the above allegation is SUBSTANTIATED. Staff were using personal communication devices to communicate resident medical information, which included pictures and text. Based on LPAs observations, interviews conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.”) Substantiatedthe state’s words, verbatim · CDSS document, Apr 18, 2024 · control 24-AS-20240305201709

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c) · Plan of correction due date: Apr 23, 2024

(c) All information and records obtained from or regarding residents shall be confidential. This requirement was not met evident by: Based on LPA observation of text messages on staff phones and staff interviews. Administrator and staff were using personal communication devices to communicate resident medical information using pictures and text, which is a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 18, 2024

Plan of correction: Licensee will implement communication binder and facility manager will work alternative shift so that a supervisor is available to provide guidance to staff. Overnight staff will call administrator when urgent issue arises. Use of text messages to communicate resident medical information will cease immediately. Licensee will submit written plan of correction on how staff will communicate resident medical information going forward to this LPA by 4/22/2024.

Allegation investigated: Staff did not ensure facility was free from pests Staff are not taking universal precautions for an outbreak

LPA toured the facility with AD and did not observe live cockroaches or other pests. AD provided LPA with pest control invoices that show this facility has Pest Control services once a month. LPA interviewed staff and AD regarding procedures used during recent COVID outbreak. AD was also in communication with Kern DPH during the outbreak for guidance. Based on interviews with staff, LPA found them to be in compliance with current COVID guidance. Unfoundedthe state’s words, verbatim · CDSS document, Feb 1, 2024 · control 24-AS-20240123143251

Allegation investigated: Staff are not providing a safe environment for residents in care

LPA toured the facility with AD and observed a thick layer of unknown white powder in 4 resident bedrooms and under the kitchen stove. LPA interviewed staff and residents. Though there is discrepancy on what the purpose of the powder is for. Powder is accessible to residents in care. Plan of Correction: LIcensee will remove powder from resdient rooms by POC date and will discontinue its use in this faclity going forward. Licensee will provide written statement on how Licensee will comply with this regulation. Substantiatedthe state’s words, verbatim · CDSS document, Feb 1, 2024 · control 24-AS-20240123143251

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Feb 2, 2024

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on observation and interviews, the Licensee did not comply with section 87303 (a). LPA observed thick layer of unknown white powder along the walls in 4 resident rooms. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 1, 2024

Plan of correction: Licensee will remove powder from resdient rooms by POC date and will discontinue its use in this faclity going forward. LIcensee will provide written statement on how Licensee will comply with this regulation.

Allegation investigated: Staff abandoned resident Resident was illegally evicted

Licensing Program Analyst (LPA) K. Kaur arrived at the facility for a subsequent visit. LPA was allowed entry by staff. LPA met with Administrator Beatriz Ponce and explained the purpose of the visit and reviewed the elements of the allegations. LPA delivered the following complaint investigation findings. The Department investigated the allegations listed above. Based on interviews conducted and records reviewed the resident (R1) wanted to leave and no longer wanted to reside at the facility. Facility representative took resident to a shelter who signed a statement indicating intent to leave. Based on observation and interview of staff and residents, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur, therefore these allegations are unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 5, 2023 · control 24-AS-20230828121121

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.