Regency Place

Type of visit: Case Management - Legal/Non-compliance

A Non-Compliance Conference (NCC) was conducted on this day, 08/21/2026 by the Sacramento South Regional Office via Microsoft Teams. The purpose of this NCC meeting was to discuss the high volume of deficiencies and the inability of this facility to remain in substantial compliance with regulations. Present at the meeting were Regional Manager (RM), Stephenie Doub, Licensing Program Managers (LPMs), Arielle Pascua and Stephen Richardson, Licensing Program Analyst (LPA), Sulma Lopez, Facility Administrator Martin Nichols, and Licensee representatives Steven Kregel and Julie Myers. The Non-Compliance Conference process was explained during this meeting to include the administrative process. During the review period from January 2025 to July 31, 2026, the facility has received (6) Type A violations citations regarding Neglect/ Lack of Supervision, (1) Type A violation citation for Physical Abuse/ Corporal Punishment, (1) Type B citation regarding Reporting Requirements, and (1) Type A citation for Medication Administration. Licensee agreed to do the following in order to bring the facility into compliance no later than the following date 08/272026: - Provide documentation of last in-service training on Post- Fall Assessments. - Provide documentation of last in-service training on Fall Procedures. - Provide documentation of last in-service training on when to call 911. - Provide documentation of last in-service training on Personal Rights. - Provide documentation of last in-service training for Medicine Technicians. Continued on LIC 809-C... -Copy of LIC500 and LIC308 -Continue in-service training for Post-fall assessments, fall procedures, 911, personal rights, medication technicians at least every 6 months. Community Care Licensing Department (CCLD) will do the following: - Increase monitoring to quarterly visits. - Licensee was offered TSP. Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code, and due to the severity of the incident which resulted in the abuse of a client in care, this case has been referred to legal for review and possible administrative action. Per California Code of Regulations (CCRs) - Title 22 no deficiencies are being cited during this visit. An exit interview was conducted, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents. In addition, a copy of this report will be sent out certified mail.the state’s words, verbatim · CDSS document, Aug 21, 2026

Allegation investigated: Staff mismanage residents' medications. Staff do not seek medical attention for residents in a timely manner.

On 07/13/2026, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with the facility administrator Martin Nichols and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 78. Allegation: Staff mismanaged residents medications. It was alleged that staff mismanaged residents medications. This investigation consisted of records review. On 06/30/2026, LPA Hughes conducted a visit to the facility and reviewed resident Medication Administration Records (MAR) for seven (7) residents in care. LPA observed that the MARs reviewed were incomplete, as medication technician’s signatures documenting medication administration were missing throughout the records for all seven residents reviewed. This was observed not in compliance with Title 22 regulation 87465(c)(3). As the facility did not ensure a record of centrally stored medications included signatures of the staff who assisted with the administration of medication for all seven residents. Continuation 9099-C Substantiated Allegation: Staff do not seek medical attention for residents in a timely manner It was alleged that staff do not seek medical attention for residents in a timely manner. This investigation consisted of interviews with facility staff, and records review. On 02/26/2026 an initial visit was conducted to the facility by LPA Tomayo, resident and facility records were obtained. On 05/13/2026 SIA Belman conducted an interview with facility staff (S1) who reported that on 01/25/2026 at 1:55 AM resident (R1) fell while ambulating inside of their room. Staff (S2) stated that (R1) should have been transported to the hospital sooner as staff observed visible injuries, R1 was not transported until 1:40 PM on 01/25/2026. Additional interview with facility staff (S2) stated that residents are assessed for injuries and transported based on the severity of the injury. Staff (S2) further stated that the facility has a responsibility to request emergency services when there are visible signs of injury. Further interview with the Memory care coordinator stated that residents who are considered a fall risk are monitored closely, stating that when resident falls occur, facility medication technicians assess residents injuries and contact emergency services immediately. Records review indicated that on 01/25/2026 resident (R1) had an unwitnessed fall in which the resident was not immediately transported to the hospital due to R1’s family request, it was revealed that R1 sustained injuries due to their fall. Although R1’s family declined immediate transport, the facility remained responsible for ensuring R1 received an appropriate medical evaluation and failed to obtain further medical guidance following the fall. Based on interviews and records reviewed, the allegation is substantiated. The facility did not ensure R1 received necessary and timely medical attention following an unwitnessed fall that resulted in visible injuries. This was observed to be not in compliance with Title 22 regulation 87465(a)(2). As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. An immediate civil penalty of $500 is being issued today for Section 1569.312. The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. An exit interview was conducted, and deficiencies cited on the LIC 9099, LIC 9099-D, LIC 421IM pages and appeal rights were provided to facility. Allegation: Staff handle residents in a rough manner. It was alleged that staff handle residents in a rough manner. This investigation consisted of interviews with facility staff, and residents in care. On 06/30/2026 LPA Hughes conducted a visit to the facility. Interviewed three (3) facility staff who denied ever handling residents in a rough manner or ever observing facility staff handle a resident in a rough manner. LPA interviewed five (5) residents who did not express concerns regarding being handled in a rough manner, or ever observing other residents being handled in a rough or aggressive manner. Based on information and evidence obtained the allegation is unsubstantiated. Allegation: Staff do not provide activities to residents in care. It was alleged that staff do not provide activities to residents in care. This investigation consisted of interviews with residents in care, facility observations and records review. On 06/30/2026, LPA Hughes conducted a visit to the facility. Interview with five (5) residents (R6-R10) revealed that the facility provides a variety of activities in which residents actively participate. During the facility tour, LPA observed residents participating in a game of Bingo and later observed a resident group activity led by the facility’s activity coordinator. LPA also reviewed the facility activities calendar, which documented scheduled daily activities consistent with those observed during the visit. Based on information, evidence, and facility observations obtained the allegation is unsubstantiated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Additionally, staff (S2) stated that they witnessed resident (R2) fall while standing with other residents, stating that the resident was using their walker however still lost their balance. Staff (S2) stated that upon observation of resident (R2) fall, emergency services were contacted immediately. Records review did not indicate that facility staff failed to provide adequate care and supervision prior to the fall, as records reflected the fall was accidental in nature. Additionally, records review indicated that resident (R2) was transported shortly after the fall and did not indicate that facility staff failed to provide adequate care and supervision leading to the fall. Based on information and evidence obtained the allegation is unsubstantiated. Allegation: Staff falsify incident reports regarding residents in care. It was alleged that Staff falsify incident reports regarding residents in care. This investigation consisted of interviews with facility staff, and a review of records. On 06/30/2026, LPA Hughes conducted a visit to the facility. Interview with the facility administrator stated that, effective 06/01/2026 they became responsible for submitting incident reports and ensuring incident information is accurately documented based on information communicated by staff. The administrator stated that medication technicians typically report incidents, after which the facility interviews residents and staff, review resident records, and communicates with resident responsible parties. LPA reviewed facility Unusual Incident/ Injury Reports from January through February 2026 for residents (R1) and (R2) which did not reveal evidence of falsified information or inconsistencies to reported incidents. The information documented in the reports was consistent with the information obtained during the investigation. Based on information and evidence obtained the allegation is unsubstantiated. Allegation: Staff are inappropriately restraining residents. It was alleged that staff are inappropriately restraining residents. This investigation consisted of interviews with facility staff, and residents in care. On 06/30/2026 LPA Hughes conducted a visit to the facility. Interviewed three (3) facility staff indicated that residents are watched closely, however denied allegations of inappropriately restraining residents. LPA interviewed five (5) residents who did not express concerns regarding being inappropriately restrained or ever observing any residents in care being inappropriately restrained within the facility. Based on information and evidence obtained the allegation is unsubstantiated. Continuation 9099-Cthe state’s words, verbatim · CDSS document, Jul 13, 2026 · control 27-AS-20260225112031

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Jul 21, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care...The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care...The licensee shall provide assistance in meeting necessary medical...This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need… This requirement was not met as evidenced by: The facility did not ensure R1 received necessary and timely medical attention following an unwitnessed fall that resulted in visible injuries.the state’s words, verbatim · CDSS document, Jul 13, 2026

Plan of correction: The facility stated that an in-service training will be conducted regarding facility Emergency Prepardness and Response, the facility stated that they will partner with a Hospice agency to develop the training. The facility stated the training will be completed by 07/21/2026, the facility will provide LPA training materials used, and staff sign-in sheet by POC due date. An immediate civil penalty of $500 is being issued today for Section 1569.312.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(3) · Plan of correction due date: Jul 17, 2026

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated... resident is unable to determine his/her own need for nonprescription PRN medication… facility staff...permitted to assist the resident with self-administration.. (3) A record of each dose is maintained in the resident's record... This requirement was not met as evidenced by: The facility did not ensure that ensure a record of centrally stored medications included signatures of the staff who assisted with the administration of medication for seven (7) residents in care.the state’s words, verbatim · CDSS document, Jul 13, 2026

Plan of correction: Facility staff will conduct a medication audit by a medical professional by POC date July 17, 2026. Facility staff agrees to email LPA Hughes a copy of the medication audit report by POC date July 17, 2026. In addition, facility agrees to provide incidental and medical training to all care staff by POC date.

Allegation investigated: Facility allows untrained staff to dispense medications to residents.

On 06/30/2026, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with the facility administrator Martin and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegation above. The current census is 78. Allegation: Facility allows untrained staff to dispense medications to residents It was alleged that the facility allows untrained staff to dispense medications to residents. This investigation consisted of interviews with facility staff, and records review. On 04/27/2026 LPA Hughes conducted a visit to the facility and spoke with two (2) facility staff who stated that they have received a combination of hands-on and online training medication administration training. LPA reviewed on-going facility training records for five (5) medication technicians and did not identify any discrepancies in the required medication administration training. LPA also reviewed training records for (S3) and verified that (S3) had completed medication administration training. Continuation 9099-C Unsubstantiated On 06/30/2026, LPA Hughes conducted a follow-up visit to the facility and interviewed two (2) caregivers who stated they do not administer medication to residents in care and only medication technicians are responsible for medication administration within the facility. Based on the information obtained during the investigation, there was insufficient evidence to corroborate this allegation. Therefore, the allegation is unsubstantiated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. LPA reviewed a LIC 624 Unusual Incident/Injury Report submitted by the facility on 04/22/2026 which contained incomplete and inaccurate information regarding the incident. This was observed not in compliance with Title 22 regulation 87211(c), as the facility did not ensure that reporting requirements were followed by timely reporting suspected physical abuse to the appropriate agencies within the required time frame. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Martin and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 27-AS-20260427095649

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Jul 3, 2026

87211 Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required.... This requirement was not met as evidenced by: The facility did not ensure that reporting requirements were followed by timely reporting an incident of physical abuse of a resident (R1) to the appropriate agencies within the required timeframe of 24 hrs.the state’s words, verbatim · CDSS document, Jun 30, 2026

Plan of correction: The facility agrees to remain in compliance with Title 22 regulation 87211(c) at all times. The facility has conducted mandated reporter training for facility staff. The facility agrees to review the regulation cited and write a statement of acknowledgment of the regulation and send to LPA Hughes by 07/03/2026. The facility agrees to review the regulation cited and write a statement of acknowledgment of the regulation and send to LPA Hughes by 07/03/2026.

Allegation investigated: Staff hit resident.

On 06/30/2026, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with the facility administrator Martin Nichols and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegation above. The current census is 78. Allegation: Staff hit resident. It was alleged that staff hit a resident. This investigation consisted of interviews with facility staff and resident (R1). On 04/22/2026 LPA Hughes conducted a visit to the facility and interviewed two (2) facility staff who stated they witnessed facility staff (S3) physically strike a resident (R1) in the face on 4/18/2026 while assisting the resident with medication administration. Additional interview with the facility coordinator revealed the incident was immediately report to management on 4/20/2026, and facility staff (S3) were removed from the facility pending an internal investigation. Interview with resident (R1) stated that facility staff is nice to them, however (R1) was unable to recall the incident involving (S3). Continuation 9099-C Substantiated On 04/30/2026 LPA Hughes interviewed facility staff (S3) who stated they assisted with medication administration and denied physically assaulting (R1). Facility staff (S3) stated that they touched R1’s face only after (R1) spit out their medications. This was observed not in compliance with Title 22 regulation 87468.1(a)(3) as the facility did not ensure that resident (R1) was treated with dignity and respect and was free from physical abuse while in care. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Martin and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 27-AS-20260421084925

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jul 1, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly...(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions... This requirement was not met as evidenced by: The facility did not ensure a resident in care (R1) was kept free from physical abuse as resident (R1) was hit in the face by staff (S3) while they were assisting with medication administration.the state’s words, verbatim · CDSS document, Jun 30, 2026

Plan of correction: The facility agrees to dissassociate facility staff (S3) from the facility effective immediately. The facility also agrees to conduct training on Resident Personal Rights in RCFE's and send a copy of the staff sign-in sheet and training vendor used. The facility will send a copy of the staff disassociation via email by 07/01/2026.

Type of visit: Case Management - Incident

On 06/02/2026 Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to conduct a case management regarding an AWOL incident report received by the Dept on 06/01/2026. LPA met with the facility Administrator/ Executive Director Martin Nichols and explained the purpose of the visit. The census is 77 with 14 facility staff present. LPA Hughes interviewed the facility administrator and reviewed the incident report dated 05/28/2026. Based on interview and review of the incident report R1 exited the memory care unit and was later found near the facility's trash area on the opposite side of the property. R1 was returned to the memory care unit by the facility housekeeper after being observed outside of the designated secured area on 05/28/2026. R1's LIC 602 Physician's Report dated 01/28/2025 was reviewed by LPA Hughes which revealed that (R1) is unable to leave the facility unassisted. Based on today's case management, a citation is issued under Title 22, Division 6. An immediate civil penalty in the amount of $500 is issued in addition to citation due to absence of supervision. An exit interview was conducted with the facility Administrator/ Executive Director Martin. A copy of this report LIC 809, LIC 809-D, LIC 421IM and Appeal rights was provided at the end of the visit.the state’s words, verbatim · CDSS document, Jun 2, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 5, 2026

87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: The facility did not ensure that a resident in care (R1) was adequately supervised from wandering away from the designated memory care unit and was found near the facility's trash can. This poses in immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 2, 2026

Plan of correction: The facility will ensure compliance with Title 22 regulation 87464 at all times. The facility will conduct in-service training with all facility staff working in the memory care unit on care and supervision, and resident elopement. The facility will send LPA proof of training by 06/05/2026 via email at shakaricka.hughes@dss.ca.gov

Type of visit: Case Management - Other

On 4/14/2026 at 3:00 PM, LPA Shakaricka Hughes conducted an unannounced case management visit to the facility. LPA met with the executive director Heidi Charette. The current census is 53 with 9 facility staff present. The purpose of this visit was to conduct a resident records file review related to a complaint control: 27-AS-20260225112031. LPA reviewed and collected documents for residents R1, R2, R3, and R4. No citations were issued during this visit. An exit interview was conducted and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Apr 14, 2026

Type of visit: Case Management - Other

On 1/28/26 at 9:15am, Licensing Program analyst (LPA) Kevin Gould conducted an unannounced case management inspection to deliver an immediate exclusion order for the staff member identified as S1 (see confidential names list, LIC 811 dated 1/28/26. LPA met with R1 and Food services director Rommel Aquino. LPA met with S1 and informed them of their immediate exclusion from the facility. LPA observed S1 depart from the facility. LPA met with Food Services Director and backup administrator and informed them of S1's immediate exclusion. As R1 is identified as the active administrator LPA confirmed there is a designee as a backup to the administrator, Rommel Aquino who possesses a valid, current administrator certificate. Certificate #7010123740 and expires on 9/3/27. LPA made contact with the Licensee representative Julie Myers and informed the licensee of S1's immediate exclusion. Licensee agrees to submit documents to approve a new administrator by Friday, 1/30/26. Documents to approve a new administrator will include: LIC 200 form - application (signed by the Licensee), LIC 500 form - personnel Report with all staff and dates and times worked, LIC 501 form - personnel record (a resume or CV can be substituted if includes information required),LIC 503 form - Health screening and TB clearance, copy of administrator certificate, evidence that the appointed administrator meets the education/experience requirements for facilities licensed for 50 or more. No deficiencies observed or cited during today's inspection. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jan 28, 2026

Allegation investigated: Staff left resident in soiled briefs for extended periods. Staff left resident in the same clothing for extended periods. Staff did not meet resident’s dietary needs resulting in weight loss. Staff consumed resident’s personal food items.

On 10/17/2025, Licensing Program Analyst, Arvin Villanueva (LPA) arrived unannounced to conduct a follow up complaint visit regarding the allegations noted above. LPA met with Executive Director/Administrator, Damion Anderson (AD), and stated the purpose of the visit. Allegation - staff left resident in soiled briefs for extended periods: The investigation into this allegation consisted of record reviews, interviews and observation. Record showed that Resident 1 (R1) was diagnosed with Alzheimer’s dementia and is noted in physician reports dated 11/14/24 and 11/22/23 as being dependent on staff for all activities of daily living (ADLs), including toileting. R1 was assessed to be incontinent of bowel and bladder. Facility assessments dated 11/30/23 and 8/1/24 show that R1 requires total assistance with toileting and receives incontinence care with extensive checks and/or changes daily. R1 is also checked on at least four times per shift. {1 of 5} Unsubstantiated A review of hospice care notes from August to December 2024 shows R1 receives hygiene care, including showers, from a home health aide at least 2 times per week. No concerns were noted regarding R1 being left in soiled briefs or wearing the same clothing for extended periods. Additionally, hospice provided staff training on 7/21/24, covering incontinence care, hydration, nutrition, and skin care. Care notes from December 2023 to December 2024 document instances where R1 refused hygiene or care. R1 has been known to engage in behaviors such as smearing feces, which required housekeeping to change bed linens. These incidents were recorded as being addressed by staff. Interviews with staff consistently confirmed that residents are checked frequently, usually every two hours, and that incontinence care is part of the routine. Staff stated they have not witnessed any residents, including R1, being left in soiled briefs for extended periods. One staff stated that clothing and hygiene are addressed during regular care or sooner if needed. Resident interviews did not support the allegation. One resident stated they receives assistance when requested and did not confirm being left in soiled briefs. Another resident shared that staff assist them with changing adult brief at least twice per shift and that help is given in a timely manner. Another resident did not have any personal experience to share regarding the allegation. During observation, LPA tested a resident’s call system and noted a staff response time of approximately five minutes, suggesting staff are available and responsive to residents’ needs. Based on all gathered information, including documentation, observations, and statements from staff and residents, there is insufficient evidence to support the claim that staff left residents in soiled briefs for extended periods. Therefore, the allegation is UNSUBSTANTIATED. {2 of 5} Allegation - staff left resident in the same clothing for extended periods: The investigation into this allegation consisted of interviews, record reviews and observation. R1’s care records show that R1’s needs changed over time due to diagnosis of Alzheimer’s disease and dementia. According to the 11/30/2023 Needs and Services Plan, R1 required standby assistance with bathing twice a week and help preparing clothing. R1 was also noted to wander but could dress and move independently. However, review of 8/1/2024 Resident Assessment showed increased care needs: R1 required one-person total assistance for bathing and dressing, along with frequent toileting assistance and checks throughout the day. Hospice care was also involved, with home health aides providing hygiene care at least three times a week. R1’s Physician Report dated 11/14/2024 confirmed that R1 could no longer independently bathe, dress, toilet, or feed. Hospice records from August to December 2024 showed no noted concerns about R1 being left in soiled clothing or wearing the same clothes for long periods. Additionally, on 7/21/2024, hospice provided training to staff on topics including skin care, hygiene, and incontinence care. A review of R1’s care notes from December 2023 to December 2024 showed that R1 occasionally refused meals, medications, and hygiene care. There were also reports of behaviors such as smearing feces, requiring bed linen changes. Interviews with residents did not reveal any concerns about hygiene or clothing. None of them reported witnessing any resident being left in the same clothing for too long. They confirmed that staff provide assistance, although they wished there were more staff available. Staff interviews were consistent in stating that residents are checked frequently—every two hours or more depending on the shift. They also stated that clothing is changed during hygiene routines or when clothes are dirty. Specifically regarding R1, one staff shared that R1 required two-person assistance for care and was often provided fresh clothing. Staff denied seeing any residents left in soiled or unchanged clothing for extended periods. During an observation on 10/9/25, visiting LPAs tested a resident’s call button and staff responded within about five minutes, indicating timely care response. Based on the gathered information, this allegation is determined to be UNSUBSTANTIATED. {3 of 5} Allegation - staff did not meet resident’s dietary needs resulting in weight loss: The investigation into this allegation consisted of record reviews and interviews. According to weight records, R1’s weight changed over the year. On 1/8/2024, R1 weighed 128.8 pounds. Between February 5 and July 7, 2024, R1 experienced a significant weight loss of 15.6 pounds, dropping from 131.2 to 115.6 pounds. However, by 12/6/2024, R1’s weight increased to 133.2 pounds. R1 was admitted to hospice on 7/20/2024, with a terminal diagnosis of Alzheimer’s disease and secondary diagnosis of weight loss. Hospice records indicate that R1 had decreased functional ability, minimal food intake, and refused further hospital care. Hospice care notes from August to December 2024 show that R1 received regular visits from a home health aide at least three times a week, with no issues noted related to food intake. Hospice also trained facility staff on key topics such as nutrition, hydration, and incontinent care. A review of R1’s dietary orders confirmed that R1 was on a regular diet with no pork. The facility’s menus from April to October 2025 showed a rotating schedule of different meals for breakfast, lunch, and dinner, along with snacks between meals. The food options varied daily and included alternative meal choices. Staff interviews revealed that R1 was given Ensure supplements with lunch and dinner, and when R1 refused a meal or disliked a dish, alternate options were offered. R1’s assessment records show a progressive decline in abilities. In November 2023, R1 required minimal assistance with daily activities. By August 2024, R1 required full assistance with most activities, including bathing, dressing, toileting, and feeding. Staff documented that R1 often refused meals, medications, and hygiene care. Resident interviews did not support the allegation. Residents stated that they liked the food served, received help from staff, and did not observe any issues related to staff neglecting dietary needs. While some residents expressed they wished for more staff, they confirmed their care needs were met. Staff interviews consistently stated that dietary needs are addressed, and that staff are trained on residents’ food preferences. S4 confirmed that the kitchen maintains a list of special diets. Staff reported that residents, including R1, are checked regularly and receive assistance with meals as needed. S1 and S2 stated that R1 was assisted during meals and that R1’s food refusals and weight changes were likely due to medical condition, not from a lack of care. Based on gathered information, the allegation is determined to be UNSUBSTANTIATED. {4 of 5} Allegation - Staff consumed resident’s personal food items: The investigation into this allegation consisted of record reviews and interviews. LPA spoke with other residents in care. Residents stated that they liked the food served and did not witnessed staff take their food. One resident stated they heard rumors about staff taking items, but denied seeing it happen. None of them reported that their own food or belongings were taken. Residents interviewed also stated staff helped them when needed, though they wished there were more staff at times. Interviews with staff showed they all denied taking any resident’s food. They said that residents are checked regularly and helped with eating, hygiene, and changing clothes. Staff interviewed stated they did not see or hear of anyone eating food that belonged to residents. Review of the following records, hospice care notes and facility staff care notes, do not indicate that R1’s food items were missing. During facility visits on 10/9/25, 9/17/25, and 7/21/25, visiting LPAs did not note any staff consuming residents’ food items. Based on all the information collected, including interviews, documents, and observations, there is not enough evidence to prove that staff took or ate R1’s personal food items. Therefore, the allegation is UNSUBSTANTIATED. Note: A finding that is unsubstantiated means that 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. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was conducted with AD and a copy of this report and appeal rights were provided. {5 of 5}the state’s words, verbatim · CDSS document, Oct 17, 2025 · control 27-AS-20241216143525

Type of visit: Required - 1 Year

On 10/9/25, Licensing Program Analysts (LPAs) Cynthia Tamayo and Arvin Villanueva arrived at this facility unannounced to conduct an annual inspection visit. LPAs met with Executive Director, Damion Anderson (ED) and explained the purpose of the visit. The facility is a Residential Care Home for the Elderly, approved for age range 60 and over. Approved for 61 non-ambulatory, of which 10 may be bedridden. Approved hospice waiver for 10. ED holds Administrator Certification #7022031740 and expires 3/25/2026. LPAs and ED inspected the physical plant inside and outside to ensure there were no health and safety concerns. LPAs observed the lounge area, lobby, and common areas. In addition, the kitchen areas, dining area, and activity room were toured. Medication room was toured. Kitchen was toured for adequate food supplies and storage. A review of the facility perimeter fence, side gates, and exits was conducted. A review of the resident rooms and bathrooms were conducted. LPAs observed the facility to be free of odor, clean and in good repair at this time. LPAs observed required furniture and lighting throughout the facility. LPAs observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. Refrigerators and freezers were observed to store adequate amount of food. Temperatures for refrigerators and freezers were observed to be within regulatory standard as per observation and review of temperature log. Report continued on 809-C The hot water temperature was measured at 117.3 degrees Fahrenheit in 4 sample resident rooms. The room temperature inside the facility measured between 71 and 75 degrees Fahrenheit. Centrally stored medications, toxins, and sharp knives kept locked and inaccessible to residents. LPAs observed the fire extinguisher(s) were up to date and were last serviced on 6/25/25. Smoke and carbon monoxide detector(s) in the facility were in good repair. First aid kit was checked and are complete. Review of 7 resident files include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. Medication review of 3 residents include review of physician orders for over-the-counter medications. No issues were noted at this time. LPAs reviewed 5 staff files include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. No issues were noted at this time. Facility conducts quarterly disaster/evacuation drill and last drill was on 7/1/2024. Facility has a dementia care plan and infection control plan. The following documents were collected during today's visit: LIC 308 Designation of Administrative Responsibility, Proof of Current Liability Insurance, Resident Roster, LIC 500 Personnel Report and Staff Schedule for October 2025 The following documents were requested during today's visit: Updated infection control and disaster plan Per California Code of Regulations, Title 22, no deficiencies were cited during today's inspection. An exit interview was conducted, and a copy of this report were left at the facility.the state’s words, verbatim · CDSS document, Oct 9, 2025

The state marks this report as 6 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not provide adequate supervision resulting in resident sustaining multiple falls and injuries including a fracture. Staff are not providing adequate care and supervision to the residents.

On 9/17/2025, Licensing Program Analyst, Arvin Villanueva (LPA) arrived unannounced at this facility to conduct a follow-up complaint visit regarding the allegations noted above. LPA met with Administrator, Damion Anderson (S1) and stated the purpose of the visit. Allegation - Staff did not provide adequate supervision resulting in resident sustaining multiple falls and injuries including a fracture: The investigation into this allegation included a review of resident R1’s medical and facility records, as well as interviews. {9099-1} Substantiated Records Reviews Medical record review: R1 was admitted to hospital on December 14, 2024, after an unwitnessed fall at Regency Place. According to the facility staff, they heard the fall and found R1 on the ground with a cut on the forehead. A CT scan revealed that R1 had a fracture on the right nasal bone and nasal septum. R1’s forehead wound was cleaned and closed with Steri-Strips. R1 was discharged back to Regency Place later that evening, around 11:29 p.m. A review of R1's Needs and Services Plan, dated November 30, 2023, revealed that R1 had been identified as a fall risk upon admission to the facility. However, the plan does not appear to have been updated or adjusted in response to R1’s fall history, particularly the incidents in October 2024. At that time, R1 had already experienced two unwitnessed falls, and it was recommended by R1’s hospice to implement additional safety measures, such as a bed alarm or chair alarm. Through further review, there were no evidence that the facility took steps to address this recommendation until after the fall on December 14, 2024. In October 2024, R1’s hospice documented that R1 had suffered two unwitnessed falls. Based on this, hospice staff recommended the use of a bed alarm or chair alarm to help monitor R1’s movements and helps prevent further falls. However, the facility did not implement these measures prior to R1’s fall on December 14, 2024. Interviews: Interviews with facility staff revealed that they believe R1 requires one-on-one care, which the facility cannot provide. Staff acknowledged that they had concerns about R1’s fall risk but indicated that they were unable to provide the necessary supervision, either due to staffing limitations or the facility not being able to meet the required level of care. Additionally, through staff interviews confirmed that facility only began implementing preventive fall measures, as recommended by R1’s hospice, after R1’s fall on December 14, 2024. Based on the information gathered, there is a preponderance of evidence that the facility did not provide adequate supervision or implement appropriate safety measures for R1, despite being identified as a fall risk upon admission and after previous falls. Therefore, the allegation that the facility failed to provide adequate supervision, leading to multiple falls and injuries, including a fracture, is SUBSTANTIATED. {9099-2} Allegation – staff are not providing adequate care and supervision to the residents: Observation: During an interview with another resident R2 on 3/19/25 at approximately 10:13am, R1 was observed wandering into a R2’s room unattended. R1 was found laying on their back in R2’s bed, staring at the ceiling. R2 stated that R1 frequently engages in this behavior. When staff was called, a non-care staff arrived and escorted R1 back to R1’s own room, stating that R1 "does this all the time." This incident occurred with no apparent staff supervision in the common areas. Record Reviews: R1’s care plan, dated August 1, 2024, outlines that R1 is a fall risk, suffers from dementia, and requires total assistance with various activities of daily living such as bathing, dressing, and toileting. The plan specifically notes that R1 must be supervised at all times due to wandering behaviors and is also prone to aggressive and disruptive actions. However, there are no clear interventions noted in the plan to address the wandering or ensure that R1 is adequately supervised. Interviews: In interviews with staff, it was revealed that the memory care unit has 15 residents and is staffed with two caregivers and one medical technician per shift. The caregivers reported that they check on residents every 15 to 30 minutes. However, these checks are not consistently documented for all residents, with the exception of R1, whose checks began to be documented after the last fall in December 14, 2024, at the request of R1’s family. Despite this, staff admitted that the checks for R1 do not seem to prevent his falls, and there is no formal system to track the frequency or effectiveness of the bed alarm placed in R1’s room after R1’s injury. R1 has experienced several falls during since admission at Regency Place. According to staff, all of R1’s falls have been unwitnessed. The most serious of these falls occurred on December 14, 2024, when R1 fell in their room, resulting in a fractured nose. Staff reported that R1 was not sent to the hospital immediately after this fall, contrary to the facility’s policy, which states that unwitnessed falls should always result in a hospital visit. Staff members also acknowledged that R1’s declining vision and refusal to wear corrective glasses may contribute to these falls. {9099-3} Staff members consistently stated that R1 requires one-on-one care due to R1’s needs, including vision impairment, wandering behavior, and aggression. However, the facility does not provide the level of care needed to properly manage R1's condition. Several staff members expressed that R1’s care needs often divert attention away from other residents, compromising the quality of care for everyone. Multiple staff members acknowledged that R1’s wandering and fall risks increase when R1 is not closely supervised. During the night shift, staff reported that a caregiver is expected to monitor R1, but due to staffing limitations and other resident needs, this monitoring is inconsistent. Based on the information gathered during this investigation, there is a preponderance of evidence to support the allegation that the facility did not adequate care and supervision for R1. Therefore this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies are being cited from the California Code of Regulations (CCR) and/or the Health and Safety Code. Immediate Civil Penalty is being assessed in the amount of $500.00. At this time enhanced civil penalty assessments are under review and additional civil penalties may be assessed pursuant to Health and Safety Code 1569.49. An exit interview was conducted with S1 and a plan of corrections and the appeal process were discussed. A copy of this report and appeal rights were provided. {9099-4}the state’s words, verbatim · CDSS document, Sep 17, 2025 · control 27-AS-20241216143525

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(e) · Plan of correction due date: Sep 18, 2025

Basic Service Requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement is not met as evidenced by: Based on interviews and record reviews, R1 sustained multiple falls and injuries including a fracture due to lack of adequate supervision and did not timely implemented hospice's preventive recommendations. This poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2025

Plan of correction: Per discussion, Administrator agreed to submit a written statement of understanding of the regulation cited and submit to the Department by POC due date. Note that facility has implemented preventive plans, including bed alarms and cameras in R1's room after the last fall incident on 12/14/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 18, 2025

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on observation, interviews and record reviews, facility did not provide adequate supervision to R1. This poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2025

Plan of correction: Per discussion, Administrator agreed to submit a written statement of understanding of the regulation cited and submit to the Department by POC due date. Note that facility has implemented preventive plans, including bed alarms and cameras in R1's room after the last fall incident on 12/14/24.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Resident in care sustained multiple unexplained injuries Staff left resident on the ground for an extended period of time Staff did not provide adequate supervision to residents in care resulting in fall Staff did not provide activities to residents in care Staff did not report incident to resident's authorized representative

On 07/21/2025, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility unannounced to present findings for a complaint. LPA Campbell met with Vandita Chand, Resident Services Director and explained the purpose of the visit. Regarding the allegation that resident in care sustained multiple unexplained injuries, when contacted, F2 reported that their family member's fall was a result of R2's refusal to use a walker and that the falls decreased when she stopped being "stubborn". F3 reported that R3 did not have an abundance of falls and F3 could only recount 3 falls over the past year. Regarding the allegation that staff left resident on the ground for an extended period of time and staff did not provide adequate supervision to residents in care resulting in falls, R1 was identified in the complaint as a resident who was left on the ground as witnessed by F1. However, when contacted, F1 reported no such event and stated that staff contact her and leave messages whenever R1 is injured though F1 reports staff should make more of an effort to reach them if they don't respond. Unsubstantiated Regarding the allegation that staff did not provide activities to residents in care, LPA Campbell spoke to R4 and R5. Both confirmed that the community offers many activities though R4 doesn't consider themselves a "joiner" and R5 predominantly plays card games. Both residents interviewed were able to confirm many of the activities on the event calendar have been offered to them. Regarding the allegation that staff did not report an incident to residents authorized representatives, LPA Campbell contacted emergency contacts for R1, R2 and R3.. Of the three emergency contacts and/or family members interviewed, F1, F2 and F3 reported that staff notified them when residents fell or were injured. Due to the above noted information, 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, and therefore these allegations are UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8,no deficiencies cited. Exit interview was held and a copy of this report was given to Vandita Chand.the state’s words, verbatim · CDSS document, Jul 21, 2025 · control 27-AS-20250210142741

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cynthia Tamayo conducted an unannounced case management deficiency visit at the Regency Place II on June 17, 2025 at 2:10 P.M. LPA met with Administrator Damion E Anderson and informed them of the purpose of todays visit was to follow up on the AWOL for Sally Ebersole (R1) on 6/12/2025. An SIR was received for R1 informing R1 exited the facility unassisted (AWOL). current LIC 602 (dated 11/5/2021) indicated resident cannot leave facility unassisted. Based on record review facility was conducting hourly checks since 5/2025 for R1 due to daughter request for supporting medical verification. Hour check Log from 6/12/25 shows resident was checked on at 6:00PM at the note indicates she was in the lobby. The Med-Tech informed the S1 that R1 stated "I am going to my room". Security Camera's show resident exited the back door at 6:15PM and was found around 6:30 PM. S2 stated R1 told them they where leaving the facility to visit their daughter. S1 stated R1 was moved into Memory Care on 6/13/25. LPA toured the facility an exit door near room 27 to be propped open. S1 stated the house keeper sometimes props the door open during business hours (before 5;00PM when they are doing laundry. S1 stated they will make sure Hours keeping has a key in order to not prop doors open. S1 stated there is a sensor for the back door but there is no sensor for the door that leads to exterior as it is access for Independent Living Residents. The exit door in the dining room does not have an alarm and it locks at 7:00PM each day. There will be a new signal system put in place for exit doors. LPA Tamayo interviewed R1, and they declined leaving the facility and do not recall going out by themselves to visit their daughter. R1 is listed as Mild Cognitive Impairment (MCI). Administrator is requested updated LIC 602 and is pending Kaiser Physician appointment. Continued on 809-C LPA Tamayo reviewed Staff Roster, Staff Schedules, Resident File (R1). LPAs reviewed the Physicians Report for R1 which indicates R1 is unable to leave the facility unassisted. R1 does not have a history of elopement. Facility has conducted elopement training and has a prepared elopement bag. Additional alarms are being put in place by 7/27/2025. Based on interviews and records review, it was determined that R1 eloped from the facility without staff knowledge. R1's Physician Report (LIC 602) states that resident was not allowed to leave the facility unassisted. Facility staff shall have supervision of R1 and aware of R1’s general whereabouts at all times. Re-appraisal will be completed for R1. Deficiencies were observed and cited on the LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code. An immediate civil penalty of $500.00 is assessed for health and safety deficiency. Exit interview conducted, a copy of the report, 809-D and appeal rights given.the state’s words, verbatim · CDSS document, Jun 27, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(d) · Plan of correction due date: Jun 30, 2025

1569.312 Basic services requirements (d)) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidence by: Based on incident report, the facility did not comply with section cited above. R1 AWOL'D from facility without staff knowledge. The LIC 602 states the resident was not allowed to leave the facility unassisted. This poses an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Jun 27, 2025

Plan of correction: Licensee/Administrator shall conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. A statement of correction will be submitted by plan of correction date via email to LPA Tamayo. Facilty has relocated R1 to memory care to ensure their safety from elopment. Proof of staff training for the cited section will be completed and asignature sheet of all staff who attended will be submitted to LPA after training is finished.

Allegation investigated: Facility staff are aggressive towards residents in care. Facility is not adequately staffed to meet the needs of residents in care.

On 3/11/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to conduct a follow up complaint visit regarding the allegations noted above. LPA met with Damion Anderson, Executive Director/Administrator, and stated the purpose of this visit. Allegation: Facility staff are aggressive towards residents in care. The investigation into this allegation included interviews with staff and an Ombudsman, as well as direct observations during facility visits. Interviews with staff members (S5-S9) revealed that none of them had observed any instances of staff being aggressive towards residents in care. S5 provided additional insight, noting that some residents, particularly in the Memory Care area, have hearing deficiencies and may not wear their hearing aids. As a result, staff sometimes raise their voices to ensure that these residents can hear them. {1 of 3} Unsubstantiated While this behavior could be perceived as aggression, it is actually an attempt to facilitate communication with the residents who struggle to hear. Furthermore, S5 recounted an incident involving a former staff member, who reported witnessing another staff member (S2), tapping on a table in an effort to gain the attention of a resident. S5’s investigation confirmed that S5’s action was intended to call the resident to the table for a meal, not to display aggression. S5 emphasized that this behavior was not aggressive in nature but rather a means of communication with a resident who had hearing issues. In addition, S7 acknowledged that staff sometimes raise their voices when interacting with residents who are combative or aggressive towards them. However, S7 clarified that this is done as a response to the resident’s behavior and is not intended to be malicious. The goal is to de-escalate the situation and ensure safety for both the resident and staff. An interview with the Ombudsman, who conducted an observation at the facility on 11/14/24, further supported the absence of aggression in staff interactions with residents. The Ombudsman reported no observed instances of staff being aggressive towards residents during their visit. Finally, observations conducted by this LPA during facility visits on 11/14/24, 12/17/24, and 3/11/25 did not observe aggressive behavior by staff towards residents was noted. Based on the gathered evidence from interviews and observations, there is no substantiated claim of staff aggression towards residents in care. Reports suggest that behaviors that may be perceived as aggressive were, in fact, attempts to communicate with residents or respond to challenging behaviors, with no intent to harm or intimidate. Therefore, this allegation was UNSUBSTANTIATED. An unsubstantiated finding 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. {2 of 3} Allegation: Facility is not adequately staff to meet the needs of residents in care. The investigation into this allegation included interviews with staff members and a review of staffing records for October and November 2024. Interviews with staff members (S5-S9) collectively revealed that the facility is sufficiently staffed and that there are no significant staffing issues. The staff reported that, in the event of staff call-outs, supervisors are typically available to step in and assist with caregiving duties when necessary. Additionally, they confirmed that there are two care staff members assigned to the Memory Care unit during both the AM and PM shifts, as well as two care staff members in the Assisted Living area for each of those shifts. For the NOC shift, there is one care staff member assigned to both the Memory Care and Assisted Living units. Each shift also includes one med tech who covers both the Memory Care and Assisted Living areas. S5 further explained that, in addition to the caregiving staff, other team members such as kitchen and housekeeping staff provide additional support to ensure the well-being of residents. Furthermore, the Memory Care Coordinator is available to cover the mid-shift, offering further assistance and oversight. A review of the staffing schedules for October and November 2024 confirmed the information provided by staff. The schedules show that the staffing levels meet the reported staffing assignments, with two care staff in both Memory Care and Assisted Living for the AM and PM shifts, one care staff for the NOC shift in each area, and one med tech per shift covering both units. Based on the evidence gathered through interviews and record review, this allegation is UNSUBSTANTIATED.Note: an unsubstantiated finding 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. Exit interview was conducted and a copy of this report and appeal rights were provided. {3 of 3} A review of the training records for staff members (S1-S5) confirmed that they are consistently receiving monthly training through the Relias platform. Specifically, S1’s training records included a range of relevant and comprehensive topics such as dementia-related education, first aid, medication management, infection control, environmental cleaning, hospice care, cultural awareness, fire safety, abuse prevention, monitoring changes in residents' conditions, and resident rights. For staff members S2 and S3, additional evidence of training was provided. S2's training in 2024 included orientation sessions with various department directors. These included training on activity programs and the memory care program with the Activity/Memory Director, meal services, special diets, kitchen sanitation, and food storage with the Culinary Director, and assessment and care plan procedures, change in condition, incident reporting, fall risk management, medication administration, and infection control with the Resident Care Coordinator. S2 also received orientation from the Maintenance Director on housekeeping services, laundry, maintenance, emergency procedures, fire safety, and life safety, as well as training from the Business Office Manager on abuse/neglect policies, workplace violence policies, job descriptions, and resident safety. Finally, S2 received orientation from the Executive Director on job descriptions, responsibilities, and resident rights. Based on the interviews and record reviews, it is evident that staff members at the facility receive adequate and ongoing training. Therefore, this allegation is UNFOUNDED. *************************************************************************************************************************** Allegation: Facility staff do not follow safety practices of the facility. An investigation was conducted to determine whether facility staff are adhering to the safety practices of the facility, particularly wearing the appropriate attire while on duty. This investigation included interviews, observations, and a review of relevant records. Interviews with the Ombudsman revealed that during their observation on 11/14/24, Ombudsman did not observe any instances of staff failing to follow safety practices, including wearing inappropriate attire while on duty. Additionally, interviews with staff members (S5-S9) confirmed that they are required to wear a uniform provided by the facility, which includes a scrub top, black pants, and slip-resistant, closed-toed shoes. {2 of 3} A review of the facility's Appearance and Grooming requirements for Personal Care Assistants further supported these findings. The policy specifies that staff members must wear company-issued uniforms, black pants (excluding jeans, scrubs with ties, or leggings), and appropriate black, closed-toed and heeled shoes. This policy aligns with safety standards to ensure staff are properly attired to perform their duties safely. Additionally, a review of the company policy on slip-resistant footwear confirmed that the footwear required meets or exceeds ASTM safety standards. These shoes are designed with outsoles that provide traction on slippery floors and surfaces, further enhancing staff safety while performing their duties. Finally, during facility visits on 11/14/24, 12/17/24, and 3/11/25, the LPA conducted observations and did not note any staff members wearing inappropriate attire or deviating from the facility’s appearance and grooming policy. Based on the evidence gathered from interviews, observations, and record reviews, staff members were observed adhering to the facility's uniform policy and safety requirements, and there were no violations noted during the investigation. Therefore, the allegation that staff do not follow safety practices, particularly not wearing appropriate attire is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, or is without a reasonable basis. Exit interview was conducted and a copy of this report was provided. {3 of 3} Additionally, the Ombudsman interviewed staff member S1, who revealed that staff had not updated some residents' "Life Story Books", particularly for residents who have been at the facility for a longer duration. These books are meant to provide essential personal and life history information to ensure individualized care, but it appears they have not been regularly updated, especially for long-term residents. Based on the evidence gathered, it is substantiated that the facility has not been updating resident records, including both physician reports and life history documentation. Therefore, this allegation is SUBSTANTIATED. Note that the facility has been cited during their annual visit on 11/17/24 and deficiencies has been cleared. Exit interview was conducted and a copy of this report was provided. {2 of 2}the state’s words, verbatim · CDSS document, Mar 11, 2025 · control 27-AS-20241112131122

Allegation investigated: Questionable death Resident sustained pressure injury due to neglect Staff did not seek timely medical attention for resident in care Resident sustained unexplained injuries while in care

On 01/07/25 at 10:15 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Resident Services Director, Alvin Gaoat and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 81. It was alleged that there is a questionable death of a resident in care. This investigation consisted of records reviewed. Based on resident 1 (R1)’s death certificate it was list that the cause of death was Parkinson’s disease with onset to “years.” Records also revealed that other significant conditions contributing to R1’s death but not resulting in the underlying cause of death were vascular dementia and chronic obstructive pulmonary disease. R1 was placed on hospice care on 10/25/22 and passed away on 12/21/22. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA was unable to corroborate the allegations. Continued LIC 9099-C Unsubstantiated It was alleged that resident sustained pressure injuries due to neglect. The investigation included interviews with facility staff and a review of records. LPA Truong interviewed 6 facility staff members. Two of the staff stated that (R1) may have had skin injuries but could not recall or confirm any such injuries. The records review revealed that R1 was under hospice care with Bristol Hospice. According to Bristol Hospice records, R1 was seen by a hospice nurse, with visit summaries from 09/08/22, to 09/23/22. A hospice notes from 09/14/22, indicated that R1 had a pressure injury in the posterior lumbar area that appeared to be a stage two injury, which had healed or 100% epithelialized. A registered nurse performed wound care for R1. Additionally, a hospice notes from 09/21/22, confirmed that the wound on the R1’s buttocks was fully healed. R1 was discharged from Bristol Hospice on 09/23/22, due to being outside the service area. On 10/25/22, R1 began receiving hospice services from Accent Care. Based on the interviews and statements gathered during the investigation, LPA was unable to corroborate the allegation. It was alleged that staff did not seek timely medical attention for resident in care. This investigation consisted of records reviewed. It was learned that on 09/23/22 (R1) was transported to Methodist Hospital of Sacramento for a chief complaint of right hip pain and impaired mobility. The radiology report stated that R1 sustained an impacted fracture over the right femoral neck due to a possible fall. There are inconsistent statements from staff regarding whether R1 sustained a fall resulting in the hip fracture. There are no direct witnesses, and it is unclear when the possible fall may have occurred. Furthermore, hospice records indicated Regency Place did not report any falls to hospice staff. Hospice staff also assessed R1 multiple times between 09/08/22 and 09/21/22 and no pain or discomfort was noted. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA was unable to corroborate the allegations. It was alleged that the resident sustained unexplained injuries while under care. The investigation involved interviews with facility staff and a review of records. LPA Truong interviewed 6 facility staff members. One staff member stated that they "think" the resident had a fall and was taken to the hospital. However, there were inconsistent statements from staff regarding whether R1 fell and sustained injuries. Additionally, there were no direct witnesses who could confirm that R1 had sustained injuries while in care. A review of the hospice records revealed that Regency Place did not report any falls to the hospice staff. Based on the interviews and statements obtained during the investigation, LPA was unable to corroborate the allegation. Continued LIC 9099-C The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. An exit interview was held, and a copy of the report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Jan 7, 2025 · control 27-AS-20240402153118

Type of visit: Required - 1 Year

On 11/14/24, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct an annual inspection visit. LPA met with Executive Director, Damion Anderson (ED) and explained the purpose of the visit. ED holds Administrator Certification # 6055657740 and expired on 3/25/2024. Per ED, he has submitted the required documents for renewal and it currently on a pending status. The facility is licensed to serve 61 non-ambulatory residents, of which 10 may be bedridden. Hospice waiver approved for 10. LPA and ED inspected the physical plant inside and outside to ensure there were no health and safety concerns. LPA observed the lounge area, lobby, and common areas. In addition, the kitchen areas, dining area, and activity room were toured. Medication room was toured. Kitchen was toured for adequate food supplies and storage. A review of the facility perimeter fence, side gates, and exits was conducted. A review of the resident rooms and bathrooms were conducted. LPA observed the facility to be free of odor, clean and in good repair at this time. LPA observed required furniture and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. Refrigerators and freezers were observed to store adequate amount of food. Temperatures for refrigerators and freezers were observed to be within regulatory standard as per observation and review of temperature log. The hot water temperature was measured at 118 degrees Fahrenheit in 4 sample resident rooms. The room temperature inside the facility measured between 71 and 75 degrees Fahrenheit. LPA observed centrally stored medications, toxins, and sharp knives kept locked and inaccessible to residents. LPA observed the fire extinguisher(s) were up to date and were last serviced on 6/7/24. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. First aid kit was checked and is complete. Report continued on 809-C Review of 8 sample resident files (R1 - R8) include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. Issues were noted: R5 did not have updated Physician's Report for review during this visit. Last Physician's Report on file was on 7/21/20. Per interview with ED confirmed they do not have the document on file for review but informed they sent the form to R5's physician. Medication review of 2 sample residents (R1 and R2) include review of physician orders for over-the-counter medications. No issues were noted at this time. Review of 6 sample staff files (S1 - S3) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. No issues were noted at this time. Facility conducts quarterly disaster/evacuation drill and last drill was on 10/2/24. Facility has a dementia care plan and infection control plan. The following documents were obtained during today's visit: LIC 308 Designation of Administrative Responsibility, Proof of Current Liability Insurance, Resident Roster, LIC 500 Personnel Report and Staff Schedule for October 2024 and November 2024. Per California Code of Regulations, Title 22, deficiencies were cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Nov 14, 2024

Allegation investigated: Staff did not follow proper reporting requirements

On 10/8/24, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to deliver the findings for a complaint investigation regarding the allegation above. LPA met with Resident Services Director Alvin Gaoat and explained the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on interviews and records review, it was learned that the facility did not follow the reporting requirement as required. The following incidents were not reported: On 5/22/2022, resident (R1) was rushed to the hospital and diagnosed with an UTI. On 9/23/2022, R1 was diagnosed with a fracture on the right pelvic hip at Sacramento Methodist Hospital. There were no incident reports found of any unwitnessed falls related to this injury. On 12/1/2022, R1’s family discovered a laceration on the R1’s right knee. Based on records review, there were no incident reports pertaining to the incident above being sent to Licensing. As a result of this investigation, LPA finds the allegation above to be SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Regarding the allegation, “Staff gave resident discontinued medications”, LPA obtained the following information through interviews and records review. Based on records review, it was learned that Morphine and Lorazepam were PRN and were not administered to R1. A review of R1’s Medication Administration Record (MAR) revealed that Morphine and Lorazepam were not administered to R1. As a result of the investigation, LPA finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and a copy of the report was provided upon exit.the state’s words, verbatim · CDSS document, Oct 8, 2024 · control 27-AS-20240402153118

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 22, 2024

87211(a)(1) Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require. A written report shall be submitted to the licensing agency and to the person responsible… This requirement is not met as evidence by: Based on observations and records review, the licensee did not ensure to report incidents via a written report or verbal communication to community care licensing, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: Licensee agrees to conduct an in-service staff training on reporting requirements. Licensee further agrees to send the Department a copy of a sign-in sheet for this training by the POC due date. Licensee shall review section 87211 and submit a statement acknowledging understanding of regulations by POC due date.

Type of visit: Case Management - Incident

On 8/23/24, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a case management visit regarding an incident report the Department received on 8/16/24. LPA met with Administrator Damion Anderson and explained the purpose of the visit. The purpose of this case management visit is to follow up on an incident occurred on 8/12/24. Resident (R1) is a 102-year-old resident with dementia who eloped from the facility on 8/12/2024. R1 was last seen at 12:50 PM and was found outside of the community’s grounds at 1:15 PM by facility staff returning from lunch. Based on interviews and records review, it was determined that R1 eloped from the facility without staff knowledge. R1's Physician Report (LIC 602) states that resident was not allowed to leave the facility unassisted. Facility staff shall have supervision of R1 and aware of R1’s general whereabouts at all times. Deficiencies were observed and cited on the LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code. An immediate civil penalty of $500.00 is assessed for health and safety deficiency. Exit interview conducted, a copy of the report, 809-D and appeal rights given.the state’s words, verbatim · CDSS document, Aug 23, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(d) · Plan of correction due date: Aug 26, 2024

Basic services requirements: Every facility required to be licensed under this chapter shall provide at least the following basic services:...(d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidence by: Based on incident report, the facility did not comply with section cited above. R1 AWOL'D from facility without staff knowledge. The LIC 602 states the resident was not allowed to leave the facility unassisted. This poses an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Aug 23, 2024

Plan of correction: Licensee/Administrator shall conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. A statement of correction will be submitted by plan of correction date of 8/26/2024 via email to LPA Tung Truong. Proof of staff training for the cited section will be completed and asignature sheet of all staff who attended will be submitted to LPA after training is finished. Immediate civil penalty of $500.00 is assessed for health and safety deficiency.

Type of visit: Case Management - Incident

On 5/2/24, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a case management visit regarding an incident report the Department received on 4/12/24. LPA met with Administrator Damion Anderson and explained the purpose of the visit. The purpose of this case management visit is to follow up on an incident that was occurred on 4/11/24. Per incident report, staff (S1) was in the activity room providing supervision over the resident. S1 noticed smokes coming from the kitchen stove top. S1 turned off the electric stove and removed a food serving tray from the stovetop to the sink to attempt to put out the fire. Staff (S2) grabbed a fire extinguisher form the front lobby and began extinguishing fire. During today’s visit, LPA Truong toured the facility and interviewed staff. It was learned that staff (S3) might have accidentally turned on the stove when setting the food tray on the stove. The plastic food tray was melted causing a small fire. It was learned that staff was present during the incident and no residents were harmed. The fire only causing damage to the food tray. Administrator was advised that additional interviews are needed in order to make a determination. No deficiencies were observed during today’s visit pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, May 2, 2024

Type of visit: Required - 1 Year

On 10/24/23, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection. LPA met with Administrator Damion Anderson and explained the purpose of the visit. Administrator holds certification # 6055657740 and expires on 3/25/2024. The facility is licensed to serve 61 non-ambulatory residents, of which 10 may be bedridden. Hospice waiver approved for 10. There are 46 residents in care currently. LPA toured and inspected the physical plant inside and outside to ensure there were no health and safety concerns. LPA observed the lounge area, lobby, and common areas. In addition, the kitchen areas, dining area, and activity room was toured. Medication room was toured. Kitchen was toured for adequate food supplies and storage. A review of the facility perimeter fence, side gates, and exits was conducted. A review of the resident rooms was conducted. LPA observed the facility to be free of odor, clean and in good repair. LPA observed required furniture and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The hot water temperature was measured at 119.1 degrees Fahrenheit. The temperature inside the facility measured at 74.0 degrees Fahrenheit. LPA observed centrally stored medications, toxins, and sharp knives kept locked and inaccessible to residents. LPA observed the fire extinguisher(s) were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. First aid kit was checked and is complete. Proof of current liability insurance was observed. Report continued on 809-C LPA requested resident and staff files for review. LPA reviewed six (6) resident files and five (5) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews. The following documents were obtained during today's visit: LIC 308 Designation of Administrative Responsibility, Administrator Certificate, and Proof of Current Liability Insurance, LIC 500 Personnel Report and LIC 610 Emergency Disaster Plan. Per California Code of Regulations, Title 22, no deficiencies were cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 24, 2023