Regents Point

Allegation investigated: Facility staff are aggressive with resident. Facility staff did not communicate about the resident's incident appropriately.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegations. LPA spoke with Melinda Forney, Executive Director and Sheila Weathers, Director Wellness, and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, facility file review, resident file review, interviews conducted, and copies of pertinent records. It is alleged that facility staff are aggressive with resident. Record review progress notes revealed the following: February 8, 2026, Charge nurse tried to calm the resident (R1) down, but the resident did not want to let go of the blanket. The resident tried striking at the charge nurse. Charge nurse assisted the resident by taking R1 outside, but the resident kept going in circle. Charge nurse called the son and Unsubstantiated when the charge nurse passed the phone to the resident to talk to the son the resident hides the nurse’s station phone inside their bag. Charge nurse tried to retrieve the phone, but the resident started striking at the nurse. After a couple minutes of the resident holding onto the phone and striking at the nurse, the charge nurse got the bag from the resident and retrieved the phone from the resident. February 16, 2026, Resident demanded to go back to bed. It was also observed by this nurse and CNA that resident was hitting themselves (right hand to her right leg). This nurse tried to stop the resident. Resident continued and was very upset. February 19, 2026, at 3:38pm resident was observed to be confused and verbalized wanting to go outside "run home". nurse and CNA attempted redirection, however resident became combative, hitting nurse and CNA and striking themselves by hitting their legs. February 24, 2026, Resident refused to stay in her room and aide assisted resident to the activity room. Resident was very anxious and agitated. At 1:30pm resident stated that they wanted to go home and resident became combative. Interview with 2 of 2 staff stated that R1 was observed with a change of condition by R1 becoming combative, agitated and combative with staff. Facility has cameras in common spaces, and it was observed that videos were looked at and saw nothing but redirecting and there was no aggressive behavior. Interview with 6 of 6 of the residents stated they had not seen staff being aggressive towards any resident. It is alleged that facility staff did not communicate about the residents’ incident appropriately. Records review revealed progress notes dates from February 08, 2026, to March 25, 2026, on all incidents staff notified son of R1 of the incidents. On numerous occasions calls went unanswered and voicemail was full so that staff would not be able to leave a message. The notes reflect 2/8/26 charge nurse called son to calm R1 and son came to facility to aid, 2/10/26 unwitnessed fall, daughter in law was in lobby at time of incident and was notified, daughter in law present when paramedics arrived, 2/16/26 at 1:10pm resident tried to walk out of facility and was redirected at 2:24pm son was notified, 2:45pm daughter in law arrived to facility, 2/19/26 resident was combative resident called son and spoke to him, son arrived at 4:00pm to aid with resident, 2/23/26 receive medication change son notified, 2/24/26 resident was agitated and son was notified, medication was updated and son was notified, 3/2/26 resident was anxious son notified and stated they would arrive to facility at 1:00pm, 3/3/26 unwitnessed fall 4:31pm son notified the son at 4:46pm multiple times but calls went straight to voicemail, 3/7/26 resident refused medication son notified and he was ok with resident refusing medication, 3/7/26 unwitnessed fall at 3:40pm attempted to notify son from 4:02pm – 4:19pm no answer and voicemail message left at 4:19pm son returned call, 3/7/26 resident had an unwitnessed fall at 10:50pm and attempted to notify son at 10:59pm and was unable to leave message, 3/8/26 resident was drowsy and refused medication and son was notified and son agreed to refusal, 3/10/26 resident had an unwitnessed fall at 10:35pm and son was notified at 11:20pm, 3/12/26 resident had and unwitnessed fall at 5:12pm and son was notified at 5:28pm, 3/21/26 resident had an unwitnessed fall at 12:30am and son notified at 1:10am, and 3/21/26 resident was observed to be anxious son was notified. Interview with 2 of 2 staff stated that family was always notified of incidents, and/or family was present during the incidents. Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegations are deemed Unsubstantiated. An exit interview was conducted with the facility representative and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Jul 20, 2026 · control 22-AS-20260320144228

Allegation investigated: Staff did not give resident medication as prescribed. Staff did not keep resident's authorized person informed about the resident's care. Facility is not conducting reappraisal properly.

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. It was alleged staff did not give resident medication as prescribed, staff did not keep resident's authorized person informed about the resident's care, and facility is not conducting reappraisal properly. LPA conducted interviews with staff. LPA reviewed records obtained. The investigation determined as follows: Regarding the allegation staff did not give resident medication as prescribed, it was reported staff is crushing Resident 1 (R1)'s medications without a physician's order. Interviews with nine out of eleven staff stated they have not crushed medications without a physician's order. One out of the remaining three staff stated they are unaware of any medications crushed prior to January 24, 2026. The two remaining staff did not add anything relevant to the allegation. Unsubstantiated Interview with Witness 1 (W1) stated they had not observe medications being crushed during their visits with R1 in the mornings but understood some medications administered in the evenings were crushed via their spouse. Record review revealed a physician's order dated January 24, 2026 indicating medications may be crushed as appropriate. An updated order dated February 10, 2026 specifies four medications as "may be crushed" including Lorazepam with a start date of January 11, 2026, Acetaminophen with a start date of December 15, 2025, Midodrine with a start date of December 15, 2025, and Simethicone with a start date of December 15, 2025. Regarding the allegation staff did not keep resident's authorized person informed about the resident's care, it was reported the staff did not inform the responsible party that apple sauce was being used to assist R1 with swallowing medications. Interviews with five out of eleven staff stated R1's responsible party brought their own apple sauce to be used to assist with administering medications for R1. Three of those five staff added R1's family was aware that apple sauce was being used to assist with administering medications. One of the remaining six staff stated R1's responsible party would assist R1 with administering medications using apple sauce. The remaining five staff did not add anything relevant to the allegation. Interview with W1 stated they did not have any concerns with staff using apple sauce to assist R1 with swallowing medications. Regarding the allegation facility is not conducting reappraisal properly, it was reported R1 was not assessed properly using their native language. Interviews with one out of eleven staff stated they completed an assessment February 2025 with R1's family member present. The staff added they attempted to complete another assessment November of 2025 but was unable to complete because R1 chose not to participate. R1's family member was present as well. The staff member does not believe there was a language barrier with R1. One out of the remaining ten staff stated they completed an assessment December 2025 and February 2026. The staff member stated R1's English was "impeccable". One out of the remaining nine staff stated when an appraisal is completed, they provide the appraisal to management to review with resident families. One out of the remaining eight staff stated during a meeting held with R1's family after the appraisal was completed February 2026, R1's family asked for a reappraisal to be done with a translator. The staff member agreed to the request and began the search for a translator prior to R1's decline. The remaining seven staff did not add anything relevant to the allegations. Interview with W1 stated the facility staff agreed to look for a translator to do a reappraisal at the family's request during the February 2026 meeting. W1 added they were present during the attempted assessment last year. Record review revealed R1's physician's report dated January 2, 2026 indicates R1 is able to communicate needs. Staff progress note indicated an assessment was attempted on November 7, 2025 but R1 declined to answer any questions. Family member was present during the attempted assessment. R1's assessment was completed on December 5, 2025 indicating R1 needed assistance with their cognitive functions. Based on interviews and record review, the above allegations are therefore deemed unsubstantiated meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of the report was left with the facility representative.the state’s words, verbatim · CDSS document, Jun 5, 2026 · control 22-AS-20260123144440

Allegation investigated: Staff did not check on resident in a timely manner

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to begin the investigation into the complaint allegation listed above. LPA explained the purpose of the visit upon entry. The complaint investigation consisted of interviews and document review. Regarding the allegation: Staff did not check on resident in a timely manner During the investigation it was discovered the alleged victim is not an Assisted Living (AL) or Memory Care (MC) Resident. LPA Haley reviewed the resident roster for Assisted Living and Memory Care. The individual was not admitted to either level of living in the community. Based on the information gathered through interview and document review, the allegation is deemed unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Jun 3, 2026 · control 22-AS-20260527155209

Type of visit: Case Management - Health Checks

On May 4, 2026, Licensing Program Analyst (LPA) Garlli Tat conducted a case management inspection for the purpose of following up on a self-reported incident report received by the Department on April 16, 2026 regarding a medication error involving Resident #1 (R1). LPA met with Executive Director (ED) Melinda Forney and Nurse Manager Sheila Weathers and discussed the purpose of the inspection. The incident report states that on April 11, 2026, R1 received wrong medications, medication nurse notified Medicine Director who advised facility staff to monitor R1 and report any changes, R1 was monitored, and additional training was conducted to avoid future medication errors. During today’s inspection, LPA conducted a health and safety check on R1, observed no health and safety issues, and observed R1 was in good health and good spirits. LPA inspected the medication room, observed it to be clean and organized, and observed no health and safety issues. LPA interviewed the Nurse Manager who confirmed the information in the incident report and provided the following information: the medication error involved R1 receiving four medications not intended for that resident; the error was made by Staff #1 (S1) who was in training at the time of the incident; the facility notified the doctor and observed R1; family was notified, there were no complications with R1 and the doctor did not recommend sending R1 to the hospital. LPA reviewed training records showing that S1 completed the in-service on April 14, 2026. Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, May 4, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 81075(b) · Plan of correction due date: May 5, 2026

Health-Related Services: (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not evidenced by: Based on interviews and documentation, the licensee administered Donepezil 5mg, Amantadine 100mg, Finasteride 5mg, and Tamsulosin .4mg to Resident #1. These medications are not intended for R1, which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 4, 2026

Plan of correction: During the inspection, Nurse Manager provided proof of in-service on medication for staff who caused the medication error. In-service was completed on 04/14/2026. Proof of training was submitted to LPA on 05/04/2026. Deficiency has been cleared.

Allegation investigated: Residents were not evaluated for proper medical care. Residents were not receiving hygiene care.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on June 6, 2024. LPA was greeted and granted entry into the facility and met with Nurse Manager (NM) Sheila Weathers, Wellness Director Ashley Croslin and Executive Director (ED) Melinda Forney. LPA explained the reason for the visit. This Department has investigated the complaint alleging that Residents were not evaluated for proper medical care. Regarding the allegation the following was revealed: During the course of the interviews with individuals ten of eleven individuals interviewed denied the allegations. During the investigation LPA reviewed the Regents Points Resident roster dated June 12, 2024. Per Resident roster, three of four residents mentioned on the complaint are not residents at Regents Point, #300603257. LPA was able to interview Resident 4 (R4) who matches one of the resident names. R4 denied the allegations. During the interviews with staff, Staff 1 (S1) reported that the residents are being evaluated for proper medical care. CONTINUED ON LIC9099-C... Unsubstantiated S2 stated that staff do a good job at assessing the residents and determining if a resident needs to go to the Hospital. Regarding the allegation that Residents were no receiving hygiene care, the following was revealed: During the course of the interviews with residents, R4 reported that she does not need much assistance and stated that her hygiene needs are being met. Per R5 through R9, they are receiving hygiene care and/or reported that they get assistance with showers, with washing their clothes and bedding and with cleaning their apartment. During the interviews with staff, S1 reported that staff follow a shower schedule. S1 stated that housekeeping cleans the apartment and stated that the laundry staff assist with washing the bedding and clothes. Per S2, staff help the residents with their shower and reported that some residents refuse to shower. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with facility representative, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Feb 3, 2026 · control 22-AS-20240606125839

Type of visit: Required - 1 Year

On January 21, 2026, Licensing Program Analysts (LPA) William Vanegas made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by staff, after explaining the purpose for the visit. Executive Director (ED) Melinda Forney was present and assisted on today's visit. LPA observed that ED Melinda Forney has a valid Administrator certificate which expires on July 22, 2027. The total capacity for the facility is 399, of which 60 can be non ambulatory and a hospice waiver for 12. The census during today's visit is, 326 of which 285 are in independent living, 38 in assisted living, and 6 in memory care. LPA Vanegas began a tour of the facility and observed the following. The facility consists of three buildings, one of which is a five story building that is utilized for independent living residents. The two additional buildings at the facility are two stories tall, one of which is for memory care, and assisted living, and the other for skilled nursing facility. Each building consist of resident apartments, with bathrooms located in the suites, a commercial kitchen, a dining room, a wellness center, a gym, a salon, laundry rooms, medication rooms, activity rooms, and storage rooms. LPA, accompanied by the ED, conducted a tour of the interior portions of the facility. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected a total of 10 resident apartments. LPA observed resident apartments to be clean and free of any hazards. LPA observed resident apartments to have the required furnishings such as a bed, a chair, a chest of drawers, a reading lamp, and enough storage space to store personal belongings. LPA observed resident beds to have clean linens and blankets. LPA tested the call buttons in resident apartments and they tested operational. LPA inspected the resident bathrooms and observed them to be clean. LPA observed resident bathrooms to be equipped with grab bars, slip resistant floor mats and a shower chair. Faucets and toilets were operational. Hot water measured from 116.2 to 117.6 degrees Fahrenheit. CONTINUED ON 809 C LPA observed that all fire extinguishers were fully charged. LPA observed emergency evacuation chair at each stairway in the assisted living/memory care building. LPA observed the required postings and the PUB 475 poster posted in the lobby of the assisted living/memory care building as well. LPA and ED toured the kitchen. LPA observed that the facility had the required two day perishable and seven day non-perishable food supply. The refrigerator and freezer were operated at the required temperatures. Facility had the required three day supply of emergency food and water. LPA observed extra linens stored in a supply closet. LPA toured the outside of the facility and observed there was a shaded seating area for resident use. There were no obstacles or hazards observed inside or outside of the facility. LPA and the ED toured the memory care unit. Memory care unit has a secured perimeter with delayed egress exits. LPA verified the delayed egress exits and the signal call system were operational. LPA reviewed 10 staff files. All staff whose files were reviewed are background cleared and associated to the facility. All 10 staff members had the required training. LPA reviewed 10 resident files and medication. No discrepancies observed in the resident files or in the medication files. Facility has a dedicated internet device for resident use. The last emergency drill was conducted on December 21, 2025. Smoke detectors and carbon monoxide detectors were last tested on December 12, 2025. Based on today's observations during the inspection, deficiencies are not being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted with ED Melinda Forney and the Director of Wellness Ashley Croslin and a copy of the report was provided to facility, and a copy will be mailed to the facility as well.the state’s words, verbatim · CDSS document, Jan 21, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced case management visit at the facility to follow up on an incident report received by the Department on 11/14/2025. For this visit, LPA Rodriguez met with Nurse Managers- Melissa Goldman and Sheila Weathers. Per incident report, resident 1 (R1) sustained a fall at the facility in room, on 11/10/2025, due to getting foot caught in foot rest of wheelchair, to which resulted to R1 sustaining an ankle fracture. Per documentation review of R1's files, R1 has been referred to as a fall risk since being diagnosed with a stroke and left-sided weakness as of this year. LPA observed that R1 is currently recovering at the facility and is doing well. R1 has a 24-hour caregiver and is obtaining services from hospice. Per documentation review, interviews and observations, R1's fracture was due to an accidental fall, and not due to staff neglect. For this visit, no health and safety concerns were observed. No citations issued. An exit interview was conducted with Nurse Managers Goldman and Weathers. A copy of this report was explained and provided.the state’s words, verbatim · CDSS document, Nov 25, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced case management visit at facility to follow up on an incident report the department received on 10/8/2025. For this visit, LPA Rodriguez met with facility administrator (AD) Ashley Croslin. Per incident report, resident 1 (R1) sustained a fall at the facility on 10/3/2025, which resulted into R1 sustaining a fracture on the knee. Per incident report, it stated that R1 fell due to R1 reporting that the texture of the floor was uneven. During this visit, LPA observed that the floor where R1 tripped, was a flat wooden surface, and was free of any hazards and obstructions. LPA observed video footage of the incident and observed that R1 was walking on a flat surface floor, and was on the way to the health and wellness office, however while walking, R1 accidentally tripped on their own feet, which resulted to R1 sustaining a injury. LPA met with R1 who is recovering, getting physical therapy and was observed to be doing well. For this visit, no health and safety concerns were oberved. No citations. An exit interview was conducted with AD Croslin. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Oct 23, 2025

Allegation investigated: Staff did not give resident medication as prescribed Staff did not keep resident's authorized person informed about the resident's care

On this day, Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit. The Department received a complaint on May 27, 2025, and the initial 10-day visit was conducted on June 6, 2025. The Department obtained copies of documents including in-service staff training, physician’s report, medication administration record, and admission agreement for Resident 1 (R1). It was alleged staff did not give resident medication as prescribed and staff did not keep resident’s authorized person informed about the resident’s care. During the investigation, LPA conducted interviews with staff and reviewed records obtained. The investigation determined as follows: Regarding the allegation staff did not give resident medication as prescribed, it was reported R1 had missed medication administration on more than 148 instances. Continued on 9099-C dated on 07/10/2025. Substantiated LPA interviews with three out of four staff stated R1 did not receive one medication dosage on the evening of March 2, 2025 because R1 was sleeping. The remaining one out of four staff was unsure. In addition, two out of four staff stated R1 did not receive one medication dosage on May 14, 2024 because R1 was sleeping. The remaining two out four staff were unsure. LPA records review of R1’s medication record confirm R1 did not receive one medication dosage in the evening of March 2, 2025 and May 14, 2024. In addition, LPA records review of R1’s medication record from October 2023 through June 2025 showed multiple instances of various medications not marked as being administered. Three out four staff stated that there are times when staff will forget to mark medications as administered in their medication tracking system. LPA reviewed in-service training completed on May 20, 2025 focused on medication documentation for staff involved in administrating medications. LPA observed R1’s medications in the medication room. Regarding the allegation staff did not keep resident's authorized person informed about the resident's care, it was reported the facility never told the responsible person (RP) when medication was not provided to R1. LPA interviews with three out of four staff stated RP was informed verbally on March 3, 2025 when R1 missed one medication dosage on March 2, 2025 during a visit by RP. The remaining one out of four staff was unsure. One out of four staff stated RP was not informed when R1 missed one medication dosage on May 14, 2024. The remaining three out of four staff were unsure. LPA review of R1’s medication record documented refusals and in some cases, documented RP’s presence during R1’s medication refusals. Three out of four staff stated responsible parties are usually informed about a resident’s refusal of medications. The remaining one out of four staff stated they do not notify anyone unless it’s a recurring issue. The facility did not provide any documented evidence of informing RP about R1’s refusal of medications. Based on LPA interviews and record review, the preponderance of evidence standard has been met. Therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of the report was left with the facility representative along with appeal rights.the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 22-AS-20250527184045

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jul 24, 2025

87465(c)(2) Incidental Medical and Dental Care Once ordered by the physician the medication is given according to the physician's directions. The requirement was not met as evidenced by: The facility did not give medication according to the physician's directions.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: Facility has completed in-service staff training to correctly mark medications as administered in the medication tracking system. In service training started on 5/20/2025 and is ongoing. Facilty provided copy of in-service training to LPA during initial visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jul 24, 2025

87211(a)(1)(D) Reporting Requirements A written report shall be submitted ... to the person responsible for the resident ... of the occurrence of...Any incident which threatens the welfare, safety or health of any resident... The requirement was not met as evidenced by: The facility did not inform the responsible person for medication not administered to Resident 1.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: Facility has completed in-service staff training to notify responsible party and physician for any missed medications. In service training started on 5/20/2025 and is ongoing. Facilty provided copy of in-service training to LPA during initial visit.

Allegation investigated: Resident sustained multiple falls due to lack of care and supervision Facility failed to obtain timely medical attention for residents exhibiting medical distress Facility double billed residents Staff are discouraging other staff to report incidents involving residents in care.

On 06/05/2025, Licensing Program Analyst (LPA) Cassandra Mikkelson contacted the licensee via phone and email to deliver final findings regarding a complaint that was received on 03/26/2024. **Report continued on 9099-D page** Unsubstantiated Resident sustained multiple falls due to lack of care and supervision Records reviewed indicated that facility staff had documentation of daily charting for residents in care including any incidents that occurred. Interviews conducted indicated that the facility had appropriate staffing to meet the care needs of the residents in care. The facility completed the appropriate assessments for residents in care and documented all care plan meeting with resident families or power of attorneys. The allegation that resident sustained multiple falls due to lack of care and supervision is unsubstantiated. Facility failed to obtain timely medical attention for residents exhibiting medical distress Records reviewed indicated that staff conducted status checks and observations for residents in care. Staff adequately provided timely medical care and initiated emergency services in a timely manner. Interviews conducted indicated that staff obtained timely medical attention for residents in care. Records reviewed and interviews conducted support that staff obtained timely medical attention for residents, therefore the allegation is unsubstantiated. Facility double billed residents Interviews conducted indicated that resident’s responsible party were content with the care that was being received at the facility. The resident’s responsible party did not mention that the facility had double billed for services provided. Interviews with facility management indicated that there was no discrepancy in billing or payments. The allegation facility double billed resident is unsubstantiated. **Report continued on 9099-D2 page** Staff are discouraging other staff to report incidents involving residents in care. Records reviewed indicated that staff were reporting and sending incident reports to The Department. Staff checked on residents in care based on their care needs and care plan. The staff would then report their observations and document for each resident. The allegation staff are discouraging other staff to report incidents is unsubstantiated. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 22-AS-20240326103120

Type of visit: Office

An informal conference was conducted on this date in the Orange County Adult and Senior Care Regional Office. The purpose of this office meeting was to discuss concerns regarding the facility policy and procedures. Present during this meeting was Regional Manager (RM) Marina Stanic, Licensing Program Manager (LPM) Sheila Santos, Licensing Program Analyst (LPA) Brandon Lopez, Executive Director Melinda Forney, Director of Wellness Programs Ashley Croslin, Nurse Supervisor Residential Living Melissa Goldman, and Nurse Supervisor Assisted Living and Memory Support Sheila Weathers. The following was agreed upon during today's meeting: Facility will provide a copy for the Department with an updated policy calling 911 by June 6, 2025. Facility will provide a copy for the Department of an updated Plan of Operation by July 1, 2025. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 27, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Joseph Alejandre and Nancy Guillen made an unannounced visit to conduct the required annual inspection. LPAs met with the Executive Director (ED) Melinda Forney and explained the reason for the visit. Melinda Forney's administrator's certificate expires on July 22, 2025. Facility is licensed to maintain a RCFE -Continuing Care Retirement Community. Total capacity is 399, of which 60 can be nonambulatory and a hospice waiver for 12. The census during today's visit is, independent living 275, assisted living 38, and 5 in memory care. LPAs and the ED toured the facility. LPAs inspected nine resident rooms in assisted living and memory care. All rooms had the required furnishings. Hot water measured from 117.3 to 123.4 degrees Fahrenheit. In eight out the nine rooms where hot water was measured the temperature was above 120.0 degrees Fahrenheit. LPAs observed that all fire extinguishers were fully charged. LPAs observed and emergency evacuation chair at each stairway in the assisted living/memory care building. LPAs observed the required postings and the PUB 475 poster posted in the lobby of the assisted living/memory care building. LPAs and the ED toured the kitchen. LPAs observed that the facility had the required two day perishable and seven day non-perishable food supply. The refrigerator and freezer were operated at the required temperatures. Facility had the required three day supply of emergency food and water. LPAs observed extra linens stored in a supply closet. LPAs toured the outside of the facility and observed there was a shaded seating area for resident use. There were no obstacles or hazards observed inside or outside of the facility. LPAs and the ED toured the memory care unit. Memory care unit has a secured perimeter with delayed egress exits. LPAs verified the delayed egress exits and the signal call system were operational. LPAs reviewed five staff files. All staff whose files were reviewed are background cleared and associated to the facility. All five staff members had the required training. LPAs reviewed 8 resident files and medication. No discrepancies observed in the resident files. LPAs observed resident one (R1) did not have six out of thirty-three prescribed medications. No other discrepancies observed. Facility has a dedicated internet device for resident use. The last emergency drill was conducted on December 22, 2024. Deficiencies are being cited per the Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report along with the appeal rights was provided.the state’s words, verbatim · CDSS document, Jan 15, 2025

Allegation investigated: Resident developed pressure injuries due to neglect Resident sustained an injury due to an unwitnessed fall

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility Nurse Manager Sheila Weathers and explained the reason for the visit. The Department received a complaint on 12/01/2020 and the initial 10 day visit was conducted on 12/10/2020. LPA Mendivil conducted a follow up visit on 10/25/2023. LPA Mendivil obtained copies of documents including physicians report and medical records. Regarding the allegations Resident developed pressure injuries due to neglect and Resident sustained an injury due to an unwitnessed fall, the investigation revealed the following: Based on medical records dated from 11/16/2020 to 11/28/2020 it was reported on 11/17/2020 that Resident 1 (R1) was diagnosed with a stage 1 wound on coccyx. Based on interviews with 4 out of 4 staff all indicated that R1 did not have any wounds and did not have a history of skin breakdown, when R1 was sent out to the hospital on 11/16/2020. Unsubstantiated Based on physician’s reported dated 11/20/2018 indicated that R1 is able to ambulate on their own. Per 4 out of 4 interviews with staff R1 was able to ambulate with a walker. Based on interviews with 4 out of 4 staff indicated R1 was able to ambulate quickly and needed to slow down to ensure safety, which staff would remind R1. Per interview with staff, staff indicated they would check on R1 every 2 hours and report any issues with supervisors. Therefore, based on the preponderance of evidence through records reviewed and interviews the allegations Resident developed pressure injuries due to neglect and Resident sustained an injury due to an unwitnessed fall are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 26, 2024 · control 22-AS-20201201090430

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Executive Director (ED) Melinda Forney and Director of Wellness Ashely Croslin and explained the purpose of the inspection. During the inspection, LPA conducted a tour of independent living with Nurse Manger Melissa Goldman and Health Service Coordinator Reyna Medina. LPA conducted a tour of assisted living and memory care with Nurse Manager Sheila Weathers, and observe the following: Independent living is located in the main four-story building. Assisted living and memory care are connected and located in a separate two-story building adjacent to independent living. Memory care is approved for delayed egress. Delay egress was tested and observed to be operable. There are 7 residents in the memory care unit, 36 in assisted living and 258 in independent living. Resident bedrooms had the required furnishings. LPA observed resident beds had linens and blankets. Bathrooms were observed to be free of debris and mildew, and faucets and toilets were operational. Water temperature was tested in ten resident bedrooms and tested between 107.6-120.7 F degrees. The facility has multiple shaded sitting areas; the central outdoor area includes a swimming pool, putting green, and lawn bowling. Pool was observed to be fenced and met regulation requirements. LPA observed residents engaging in leisure activities, such as reading, knitting, and strolling about the inside and outside of the facility common areas. Facility has all required Department postings. Facility has emergency evacuation chairs at the top of stairwells. Facility has a third-party contractor come into the facility to do quarterly inspections of smoke detectors and sprinkler system. Carbon monoxide detectors were tested during today’s inspection and observed to be operable. LPA observed medication rooms to be inaccessible to residents. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. (Cont. LIC809-C) LPA observed at least three fire extinguishers located on every floor of every building of the facility. Fire extinguishers were observed to be fully charged with service tags dated 8/03/23. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents. LPA reviewed 15 resident files and interviewed five staff and seven residents. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 23, 2024