Regency Fallbrook

Type of visit: Required - 1 Year

On November 21, 2025, Licensing Program Analyst (LPA), Venus Mixson made an unannounced visit to the facility to conduct the Required Annual visit, and met with the Administrator, Kari Moreno. LPA Mixson toured the facility along with the Administrator, Kari Moreno and made observations pertaining to the annual visit. The LPA inspected the facility inside and outside. There were no obstructions or debris to the indoor or outdoor passageways currently. The facility is licensed to serve seventy five (75) elderly residents; ages 60 and above; all of whom may be non-ambulatory and ambulatory, currently there are 64 residents and approximately 40 staff. The facility has an approved hospice waiver for fifteen (15) residents and ten (10) bedridden in rooms. The facility is approved for delayed egress. Physical Plant: The facility phone number is (760)728-8504, and is operable. LPA Mixson observed a sample of the resident living units, and they are equipped with required furniture as per Title 22. The LPA inspected the facility restrooms, and the hot water temperature tested within regulations. The restrooms were clean and appliances were operating appropriately at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. The LPA observed required postings such as; the Ombudsman poster, "If you See Something, Say Something" and the "Personal Rights" postings were posted in a common area. The cleaning supplies and sharp items were kept locked and inaccessible to the residents. There was a designated office for the resident and staff files and it was locked. Medications: were reviewed with the facility nurse, and were locked and inaccessible to residents. The overall facility is clean, welcoming, and the furniture is in good condition. The facility heating and other appliances were operable currently at the time of this visit. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for the residents. Dishes and utensils were in sufficient supply and stored properly. Records Review: LPA Mixson reviewed staff and resident files. There were no Title 22, Division 6 Regulation violations observed and/or cited during todays visit. An exit interview was conducted and a copy of this report was given to the Administrator, Kari Moreno.the state’s words, verbatim · CDSS document, Nov 21, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with Executive Director Kari Moreno who was informed of the purpose of the visit. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards and LPA observed the facility courtyard with outdoor furniture and shaded area for residents. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies, detergents, and the sharp and dangerous objects were locked and inaccessible to the residents in the facility's janitorial and maintenance supply rooms. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector, carbon monoxide, and facility sprinkler system was operational and is maintained annually with the last inspection dated 05/01/2024. Facility kitchen had the ability to prepare food in clean environment. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA was informed the facility receives multiple food deliveries a week. LPA observed medication in both Assisted Living and the Memory Care unit to be locked and inaccessible to residents in care. MedTechs document medication administration on the facility's electronic Medication Administration Record (eMAR). LPA reviewed four (4) staff files and training. All staff have the required personnel records on file and criminal record clearance, health screening report, and updated training along with CPR/First Aid Certification. Six (6) resident files were reviewed, and possessed all required paperwork which included Admissions Agreement, Needs and Service Plan, and Physician's Report. The listed administrator Kari Moreno possesses a current administrator's certificate with an expiration date of 05/06/2026. Facility has an updated emergency and disaster plan and Infection Control plan. LPA observed all facility exits were clear from obstructions. Facility contained multiple charged fire extinguishers located throughout the facility. Facility conducts disaster/fire drills with the last drill conducted on 10/29/2024 which met Department Requirements. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Executive Director Moreno.the state’s words, verbatim · CDSS document, Nov 7, 2024

Allegation investigated: Staff caused bruises to resident while in care. Staff failed to properly supervise staff with residents in care.

Licensing Program Analyst (LPA) Jacqueline Shaw Ross conducted an unannounced visit to deliver findings for the investigation of the complaint with the above allegation(s). LPA Shaw Ross and met with Kari Moreno, Executive Director and advised them of the purpose of today's visit. Below is a summary of the findings of the investigation: Regarding allegation "Staff inappropriately handled resident while in care.": Interviews were conducted, as well as records and photos were additionally reviewed regarding the allegation. In the morning of April 21, resident #1 (R1) was being assisted by Staff #1 (S1) for a bowel movement (BM) where R1 soiled self and areas around restroom. S1 attempted to assist R1 with cleaning and dressing, however, R1 became agitated and pushed S1 away (refusing assistance). When R1 calmed down, S1 was able to assist R1 with cleaning and dressing. Afterwards, S1 immediately reported the incident to a co-worker and facility administrator. R1 was evaluated by on-site Licensed Vocational Nurse (LVN) and no transportation was required. Over the following two days, bruising began to show and increase. Facility staff photographed the bruising, notified family members and reported to incident as required. Unsubstantiated Based on the above information, there is no evidence to support staff physically abused or was negligent in the care or treatment of R1. The investigation did not reveal that facility staff contributed to the bruises seen on both forearms and subsequent injuries sustained by R1. It is believed that R1 might have hit arms and hands on nearby restroom rails and counter. Therefore, the allegation that "Staff inappropriately handled resident while in care" is deemed to be UNSUBSTANTIATED Regarding allegation "Staff failed to properly supervise staff with residents in care." Interviews were conducted, as well as records and photos were additionally reviewed regarding the allegation. In the morning of April 21, resident #1 (R1) was being assisted by Staff #1 (S1) for a bowel movement (BM) where R1 soiled self and areas around restroom. S1 attempted to assist R1 with cleaning and dressing, however, R1 became agitated and pushed S1 away (refusing assistance). When R1 calmed down, S1 was able to assist R1 with cleaning and dressing. Afterward, S1 immediately reported the incident to a co-worker and facility administrator. R1 was evaluated by on-site Licensed Vocational Nurse (LVN) and no transportation was required. Over the following two days, bruising began to show and increase. Facility staff photographed the bruising, notified family members and reported to incident as required. Based on the above information, there is no evidence to support staff failed to provide assistance as needed or was negligent in the care or treatment of R1. The investigation did not reveal that facility staff contributed to the bruises seen on both forearms and subsequent injuries sustained by R1. Therefore, the allegation that "Staff failed to properly supervise staff with residents in care" is deemed to be UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means 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 with Kari Moreno, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 26, 2024 · control 18-AS-20220426091412

Allegation investigated: Licensee does not implement safety measures. Licensee does not provide adequate food service. Facility is in disrepair. Staff does not receive adequate training. Staff fails to report to Licensing. Admission Agreement does not meet Licensing requirements.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to conclude a complaint investigation regarding the above-mentioned allegations. LPA Correia met with Administrator Kari Moreno, identified herself, and explained the purpose of the visit. The Department’s investigation consisted of resident interviews, a facility tour, and a facility records and file review. It was alleged the Licensee did not implement safety measures. A facility tour revealed toxins and dangerous items were in locked areas/cabinets and inaccessible to residents in care. Smoke alarms and carbon monoxide detectors were operable, and fire extinguishers were present and current. A facility records review also revealed an approved infection control plan, disaster drills were being conducted per protocol. Interviews with residents also revealed no safety concerns at the facility. Unsubstantiated It was alleged the Licensee did not provide adequate food service. A facility record review revealed the facility maintains a weekly menu with nutritional meals. Interviews conducted with residents revealed being happy with the meals offered at the facility. Resident interviews also revealed the kitchen staff are very accommodating and offer substitute food when requested. It was alleged the facility is in disrepair. The facility tour also revealed the facility was well kempt and in good repair. The facility carpets were observed to be clean and in good condition, furniture and fixtures were also observed to be in good repair. The facility’s ambient temperature at the time of visit was between 74 degrees and 77 degrees Fahrenheit. A facility records review dated May 31, 2021, revealed having a contract with an outside source agency that provides ongoing maintenance to the facility central air conditioning/heating units as needed. Interviews conducted with residents had no complaints regarding the issues, such as disrepair, with the facility’s physical plant. It was also alleged facility staff did not receive adequate training and the Licensee failed to meet Licensing reporting requirements. A facility records review revealed staff are provided the appropriate training based on hired position. A records review did not reveal any evidence supporting failure to meet reporting requirements. Lastly, it was alleged the content of the facility's Admission Agreement did not meet Licensing requirements. A facility records review did not support the allegation. Based on the Department's investigation, there was not a preponderance of evidence to prove the alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Administrator Moreno to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) will be provided at the conclusion of the visit. Signature below confirms receipt of the reports.the state’s words, verbatim · CDSS document, Jun 19, 2024 · control 08-AS-20210723092920

Type of visit: Case Management - Deficiencies

On May 03, 2024, Licensing Program Analyst (LPA), Venus Mixson conducted an unannounced case management with deficiencies visit and met with the Administrator. An Unusual Incident(SIR) was received for the facility on 05/01/2024, that stated a staff intimidated a resident in care. Deficiencies will be cited. LPA Mixson introduced herself, stated the purpose of the visit, and toured the facility along with the Administrator. LPA made observation and requested and received pertinent documentation. Currently at the facility are 40 staff and 55 residents there were no observable regulation violation during the tour of the facility. There were no imminent health or safety concerns observed at the time of visit. LPA Mixson observed the facility had working utilities and was clean and organized. The LPA observed adequate staffing to provide supervision for the residents in care. LPA Mixson observed the facility had more than a two-day supply of perishable foods and seven day supply of non-perishable food items. Medications were found to be in sufficient supply and were locked and inaccessible to residents. An exit interview was conducted where a copy of this report was reviewed, explained, and provided to Administrator Kari Moreno along with the Confidential Names List (LIC811), LIC809-D and Appeal Rights.the state’s words, verbatim · CDSS document, May 3, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: May 10, 2024

Personal Rights of Residents in All Facilities to be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature…. This requirement is not met as evidence by: Based on information obtained from the Unusual Incident Report (SIR) received by the Department on 05/01/2024, the facility self reported, the licensee did not ensure that facility's residents to be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature…. which poses an immediate health, safety, or personal rights risk to a person in care.the state’s words, verbatim · CDSS document, May 3, 2024

Plan of correction: The Administrator stated that all staff will be retrained on Personal Rights, and how to communicate with the residents in care, and would proved to the Department by Friday May, 10, 2024.