Renaissance Living

Allegation investigated: Staff are not adequately trained Staff did not follow reporting requirements Staff did not treat resident with dignity Staff did not treat resident with respect

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the findings in the above-mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Gabriela Nafarrate Caregiver and Unique Edwards Administrator was notified via a telephone call. During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents, and outside sources. On April 20, 2023, it was alleged that the staff are not adequately trained. Outside Source 1 (OS1) observed the staff not being able to recognize R1's behaviors as possibly unmet needs (e.g., pain, fear, confusion). OS1 observed the staff not following the most basic person center approaches as in speak calmly and use This is an amended report from 9/12/25. Substantiated simple, clear language, avoid arguing; redirect gently. Maintain familiar routines and offer choices. The staff were not displaying good communication techniques, behavior management, and emergency response. They were not objective. The staff did not records triggers, interventions and outcomes. The staff did not utilize the basic standardized behavior tracking tools to assist R1 with adjusting to a new environment. On April 20, 2023, an allegation was received stating that facility staff did not follow required reporting procedures. Interviews conducted with staff indicated that they were familiar with reporting protocols and stated that incident reports were completed when residents exhibit unusual behaviors. However, documentation did not support these claims. A review of facility records revealed no incident reports, internal documentation, or other evidence indicating reports were completed for R1 during periods of unusual behavior. Additionally, Outside Source 4 (OS4) confirmed they were not notified of any incidents involving R1. This lack of documentation and communication was inconsistent with the facility’s obligation which requires licensees to report unusual incidents and maintain accurate records. The absence of incident reports and not notifying OS4 suggest noncompliance with reporting requirements. On April 20, 2023, an allegation was made that the facility staff did not treat the residents with dignity. Interviews were conducted with two (2) residents. The residents that were interviewed stated that staff treat them with dignity and respond to their needs in a timely and courteous manner. Outside source 3 (OS3) reported concerns regarding staff conduct and described staff as not compassionate nor professional. Outside Source 3 (OS3) stated that the facility staff were very unprofessional. The facility staff texted or called OS4 with multiple complaints that R1 was unruly and difficult to work with. Outside source 5 (OS5) reported witnessing undignified treatment towards R1 when transferring R1 to an alternative placement. OS5 was interviewed and they verified that the facility staff did not treat R1 with respect. The staff did not show dignity in packing R1's belongings when being transferred to another facility and cheering when the resident left the facility. A review of staff training records confirmed that all staff received training on resident rights regarding being treated with dignity. During the visit, staff were observed interacting with residents in a dignified and professional manner. Staff addressed residents by name, and offered assistance in a courteous way. The residents that the staff were assisting did not have dementia related behaviors. On April 20, 2023, an allegation was made that the facility staff did not treat the residents with respect. Interviews were conducted with two (2) residents. The residents that were interviewed stated that staff treat them with respect and respond to their needs in a timely and courteous manner. Interviews with two (2) staff members revealed that staff were aware of and trained on resident rights, including the importance of treating residents with respect. Staff were able to articulate examples of how they uphold these standards in their daily interactions. OS3 reported concerns regarding staff conduct and described staff as disrespectful. OS4 stated that the staff at the facility did not treat R1 with respect. OS5 was interviewed and they verified that the facility staff did not treat R1 with respect. They did not show respect in packing R1's belongings when being transferred to another facility and cheering when the resident left the facility A review of staff training records confirmed that all staff received training on resident rights. During the visit, staff were observed interacting with residents in a respectful and professional manner. Staff addressed residents by name, offered assistance in a courteous way. The residents that the staff were assisting did not have dementia related behaviors. The department has investigated the above-mentioned allegations. The Department has found that there is a preponderance of evidence to prove that the alleged violation did occur; therefore, the allegations are substantiated. An exit interview was conducted, and a copy of this report and the licensee rights (LIC 9058 03/22) were provided to Gabriela Nafarrate Caregiver. Her signature on this form confirms receipt of these rights.the state’s words, verbatim · CDSS document, Dec 9, 2025 · control 08-AS-20230813115402

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.624(c)(8) · Plan of correction due date: Jan 12, 2026

Staff training: Mandates that staff working in Residential Care Facilities for the Elderly (RCFEs) receive training appropriate to the services they provide, including dementia care if applicable. This requirement was not met as evidence by; Based on interviews the staff did not show staff training of one of six persons in care which posed a potential Health and Safety risk to person in care.the state’s words, verbatim · CDSS document, Dec 9, 2025

Plan of correction: Administrator agrees to conduct a staff dementia training for all staff and administrators by 1/12/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jan 10, 2026

Reporting Requirements: licensees to report unusual incidents i.e.injuries...significant behavioral changes to the Department and responsible parties within specified timeframes. This requirement was not met as evidence by; Based on interviews the staff did not file an incident report of one of six persons in care which posed a potential Health and Safety risk to person in care.the state’s words, verbatim · CDSS document, Dec 9, 2025

Plan of correction: Administrator agrees to conduct a staff incident reporting training for all staff and administrators by 1/12/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a)(1) · Plan of correction due date: Jan 12, 2026

Residents have the right to be treated with dignity in their relationships with staff and others. This requirement was not met as evidence by; Based on interviews the staff did not show dignity to one of six persons in care which posed a potential Health and Safety risk to person in care.the state’s words, verbatim · CDSS document, Dec 9, 2025

Plan of correction: Administrator agrees to conduct a staff personal rights, dignity training for all staff and administrators by 1/12/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a)(3) · Plan of correction due date: Jan 12, 2026

Personal Rights: Residents have the right to be accorded respect and to be free from humiliation or abuse. This requirement was not met as evidence by; Based on interviews the staff did not show respect to one of six persons in care which posed a potential Health and Safety risk to person in care.the state’s words, verbatim · CDSS document, Dec 9, 2025

Plan of correction: Administrator agrees to conduct a staff personal rights training for all staff and administrators by 1/12/2026.

Allegation investigated: Staff interacts with resident in an inappropriate manner Staff speaks inappropriately to resident

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to investigate and deliver findings for a complaint. LPA introduced herself, was granted entry into the facility, and met with Administrator Unique May, to whom she disclosed the reason for the visit. It was reported to Community Care Licensing (CCL) on November 17, 2025, Staff interacts in an inappropriate manner and speaks inappropriately to resident#1 (R1). More specifically, R1 stated that Staff #1(S1) recorded or videoed her when R1 exited their room. R1 also stated after the incident , S1 told R1 to return to thier room and spoke to them in a condescending manner. (Continued on LIC9099C) Unsubstantiated (Continued From LIC9099) Resident #1 (R1) has a documented history of psychotic behavior, including episodes requiring emergency services intervention. A recent physician report lists diagnoses of asymptomatic COVID-19 and anxiety, with no indication of mild cognitive impairment. The report also notes that R1 is non-compliant with medication and requires assistance with administration. Staff interviews revealed that no one witnessed or admitted to recording R1. S1 denied using a recording device but stated they contacted their supervisor via cellphone and placed the call on speakerphone to allow the supervisor to hear R1’s behavior and the interaction in real time. Staff denied speaking to R1 inappropriately and reported that redirection is commonly used to manage R1’s behaviors, with positive results. Resident interviews were attempted but could not be completed due to significant cognitive limitations among potential witnesses. Interviews with outside sources revealed no concerns regarding staff behavior. Two outside source confirmed witnessing psychotic episodes involving R1 and stated that staff interactions during those episodes were appropriate and professional. No inappropriate staff behavior was observed or reported by other outside sources A review of facility records revealed no complaints, grievances, or incident reports involving S1. LPA observations during the visit showed no evidence of inappropriate staff conduct or misuse of personal devices. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrato Unique to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 24, 2025 · control 08-AS-20251117153116

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Unique Maye. Licensee Richard Edwards arrived shortly after. According to the facility’s license, the facility has a maximum capacity of six (6) residents, of whom may be non-ambulatory, three of which may be bedridden. LPA toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Cooking/dining equipment and utensils were present. Two days worth of perishable and seven days worth of non-perishable food was present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water on the premises. Per Administrator, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Resident records reviewed had required documentation. Staff records reviewed contained required documentation. No deficiencies were issued on today's visit. An exit interview was conducted with Administrator Richard Edwards, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Nov 24, 2025

Allegation investigated: Staff engaged in an altercation with resident Staff left resident on the floor for an extended period of time after falling Staff inappropriately punished resident Staff did not adequately manage resident's medication

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the findings in the above-mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Unique Edwards Administrator. During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents, and outside sources. On April 20, 2023, it was alleged that staff engaged in an altercation with a resident. Interviews were conducted with two (2) staff members; one staff member denied witnessing or participating in any altercation with a resident. The other staff member provided information that showed staff did not use any methods of redirection or training on de-escalating a resident with dementia. Resident 1 (R1) was This is an amended report. Unsubstantiated observed grabbing or pulling on the staff. Staff did not demonstrate knowledge of appropriate de-escalation techniques. Interviews with two (2) residents did not yield any consistent accounts of any altercation. The residents reported that R1 had medical behaviors. R1 was not cooperative with the staff. OS3 was interviewed and stated that the facility staff conducted a pre-appraisal review and stated that they can care for residents with dementia and behaviors related to dementia. On April 20, 2023, an allegation was made that facility staff left a resident on the floor for an extended period after falling. LPA conducted interviews with staff members who provided statements confirming that they responded promptly to the resident's lying on the floor and followed proper procedures. The staff were aware that the resident has a right to not be forced to get up from the floor. R1 did get up off the floor on their own when they were ready to get up. The LPA interviewed the residents, who confirmed that staff respond quickly to falls and provide necessary assistance. Reviewed incident reports related to falls and found no evidence of staff leaving residents on the floor for extended periods. LPA Domingo verified that staff employed at the time of the report have completed training in emergency response and fall management as per Title 22 regulations. On April 20, 2023, an allegation was made that facility staff inappropriately punished a resident. LPA Domingo conducted interviews with staff members who confirmed that they follow proper disciplinary procedures and respect resident rights. LPA Domingo interviewed other residents who confirmed that they have not experienced or witnessed inappropriate punishment. Interviews with Outside sources confirmed that they have not witnessed inappropriate punishment or treatment from staff to residents. Records reviewed revealed that staff have resident rights training every year. On April 20, 2023, an allegation was made that the facility staff did not adequately manage the resident's medication. LPA Domingo conducted interviews with staff members who confirmed that they follow the medication management procedures. Interviews were conducted with two (3) staff members responsible for medication administration. Staff demonstrated knowledge of the facility’s medication policies and procedures, including proper documentation, storage, and administration protocols. Staff confirmed they had received training in medication management as required by Title 22, Section 87465, and were able to articulate steps taken to ensure medication is administered accurately and timely. (This is an amended report. page 2 of 3) Interviews with two (2) residents revealed no concerns regarding medication administration. Residents stated that they receive their medications consistently and as prescribed. One resident stated, “They always bring my medication on time and explain what it’s for if I ask.” Outside sources were interviewed, and they all stated that they have no concerns regarding the facility staff administering their medications properly and consistently. A review of Medication Administration Records (MARs) for a sample of residents showed no discrepancies. Medications were documented as administered according to physician orders. No missed doses or errors were identified during the review period. Staff training records confirmed that all personnel responsible for medication administration had completed required training, including annual updates, in accordance with Health and Safety Code and Title 22 regulations. The department has investigated the above-mentioned complaints. The Department has found that although the allegation may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur; therefore, the allegations are unsubstantiated. This is an amended report page 3 of 3 This page was left blank. This page was left blankthe state’s words, verbatim · CDSS document, Sep 12, 2025 · control 08-AS-20230813115402

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Caregiver Juana Gutierrez. Administrator Richard Edwards arrived shortly after. According to the facility’s license, the facility has a maximum capacity of six (6) residents, of whom may be non-ambulatory, three of which may be bedridden. LPA toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Cooking/dining equipment and utensils were present. Two days worth of perishable and seven days worth of non-perishable food was present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water on the premises. Per Administrator, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Resident records reviewed had required documentation. Staff records reviewed contained required documentation. No deficiencies were issued on today's visit. An exit interview was conducted with Administrator Richard Edwards, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jan 11, 2024