Reserve at Fountaingrove Memory Care T

Allegation investigated: -Facility does not have adequate staff to meet residents care needs.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Administrator, Kelly Ording. The Department received an allegation of facility does not have adequate staff to meet residents’ care needs. According to the reporting party, since beginning of March 2026 there have only been two caregivers and one medication technician working all three shifts (AM, PM, NOC) with approximately 25 residents of which approx. six are two people assists. The reporting party explains that one staff member is required to perform activities of daily living (ADL) including serving all meals, incontinence care and laundry for 16 residents, where staff have to split between “assisted care and memory care”. Furthermore, it appears like staff and resident’s responsible parties have been verbally requesting additional staffing from management, but their response has only indicated they are looking for how to fill job positions. Continue on LIC9099C... Unsubstantiated Continue on LIC9099... During the course of this investigation, LPA conducted 10-day visit, made observations, reviewed records, interviews with staff and residents in care. During LPA’s visit, LPA conducted a tour of the facility and observed three caregivers and one med-tech. Based on records review, LPA was provided with LIC 500 personnel report and staff schedules for Memory Care Unit for the months of March and April 2026 with a census of 27 residents in care which are divided into three groups with an average of six residents per group. Per staff schedules indicate that the facility had an average of one assigned caregiver on duty for a group of six residents in care and one med-technician who alternates covering the floor when they are not passing medications Also, there was additional staffing including cooker, server and housekeeping personnel, but they do not provide caregiving assistance to residents in care. Furthermore, the alarm response report dated March 01, 2026, 12:00am through April 14, 2026, 9:30am did not provide any supportive evidence regarding delays in staff response times to assist residents in care. According to administrator most of the residents are not aware of the call alert system due to cognitive challenges and it was clarified that current residents are residing at the memory care unit, but it was disclosed that the building is divided into two wings (East and West), where residents are located depending on their current care needs. Based on interviews conducted with residents (R1 & R2) and staff (S1, S2, S3, S4, S5 & S6) revealed conflicting information, resulting in LPA was unable to find any supporting evidence due to the very limited information obtained from interviews with residents and staff who indicated they could benefit by having additional staffing, because at times it gets busy between both wings, and they are suggesting to management to perform a better assessment of current residents’ care needs based on risk of elopement and behaviors, because there are more residents that have not been identified as needing two people assistance to manage their behaviors safely. However, staff recognized that the use of surveillance cameras in common areas that are monitored by the receptionist is helping to reduce elopement incidents. A finding that the complaint allegation occurs of facility does not have adequate staff to meet residents’ care needs is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, May 8, 2026 · control 21-AS-20260409145519

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management - incident visit and met with Edgar Bravo, Dining Services Director. The purpose of this case management inspection is to follow up on a self-report incident report submit to Community Care Licensing (CCL) on 02/17/2026. CCL received a self-report incident report on 02/17/2026 reporting an incident that occurred on 02/10/2026 at approximately 6am. Resident (R1) left their apartment using their walker, R1 exited through front egress doors into lobby, then exited through front lobby door, until they were found on the sidewalk in front of the community by a member of staff within 20 minutes of leaving. R1 said that they were waiting for a ride. R1 was escorted back into the community. R1 was assessed by staff and there were no injuries. During today’s visit, LPA learned that the incident happened while the staff was doing the cross over shift and there was no staff supervising the residents. Per Dining Services Director, the facility implemented a preventive measure to maintain at least one staff inside memory care unit during the shift change meeting. LPA also reviewed R1’s physician report (LIC 602) dated 3/24/2019, care plan indicates that R1 has been added to the monitor alert chart, in-service training records confirmed that staff held a training session on 2/18/26 including elopement drill documentation tool, which is included to the facility elopement procedures. Alarm book is documenting inspection dates and times when the checks are been performed. Facility Policies and Procedures regarding AWOL/Elopement were not followed. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted with Dining Service Director and copy of this report was given.the state’s words, verbatim · CDSS document, Mar 2, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(e)(7) · Plan of correction due date: Mar 16, 2026

87705(e)(7) Care of Persons with Dementia- Licensees that use delayed egress devices on exterior doors...: Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents,, including staff needed to escort residents who need supervision to leave the facility. This requirement was not met as evidenced by: Based on LPA's records review and interviews with Dining Service Director, the facility failed to prevent R1 who AWOL the memory care unit from the egress exit, pressing on it for time required will release it, alarm sounded, but staff was having cross over meeting, and they were not alerted until they found R1 in the parking lot, which is a potential risk to the health & safety of residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: The facility provided to LPA an in-service training record dated 2/18/26 with staff, also they have implemented door check monitoring log and R1 was added to the monitor alerting chart to prevent that this type of incident happens again a staff will be designated to maintain at the memory care unit during the change of shift meeting. Deficiency cleared.

Type of visit: Case Management - Incident

On 01/29/2026, at approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management - incident visit and met with Kelly Ording, Administrator. LPA is conducting a case management visit to obtain more information regarding three incident reports for medication administration errors received by the Department: one received on 12/05/2025 for an incident that occurred on 11/28/2025 involving resident 1 (R1) and staff (S1), and two received on 12/31/2025 for incidents that occurred on 12/26/2025 -- involving Resident 2 (R2) and Staff 2 (S2) and the other involving Resident 3 (R3) and Staff 2 (S2). LPA conducted an interview with Administrator and obtained documents. Facility is being cited for missed medication administration doses (see LIC809-D). The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and appeal of rights provided. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 29, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 30, 2026

Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed. Based on record review, self-report, and interview conducted with Administrator, R1, R2, and R3 did not receive their medications as directed which poses an immediate Health, Safety and/or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2026

Plan of correction: Licensee to submit proof of training conducted with staff and to ensure future medication errors do not occur to CCLD by POC due date of 01/30/2026.

Type of visit: Prelicensing

At approximately 8:15AM, Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Pre-Licensing inspection and was greeted by Denise Downey, Administrator. This is a change of ownership (CHOW) with 25 residents in care. On 02/20/2025 new property management company Onelife Senior Living LLC became effective. This CHOW is for Applicant OOC-Santa Rosa,LLC; and Onelife Senior Living LLC. Facility received an approved fire clearance dated 07/07/2025 that allows for a total capacity of 64 Non Ambulatory residents, of which 12 may be bedridden. Facility is full memory care with a Dementia Care Program on file. At approximately 8:45 AM LPA conducted a walk-through of facility with Administrator and observed the following: Facility is single story with East and West mirrored sides each containing, 32 apartments, dining rooms, courtyards, and each having an activity room. There is also a salon, commercial kitchen, private dining room, offices, common spaces, and indoor and outdoor activity spaces. Facility was clean and at a comfortable temperature with all exits free from obstruction. Facility has emergency lighting. Facility has an Infection Control plan on file. A sample size of 8 resident bathroom sinks were found to be within Title 22 Regulations of 105 degrees F to 120 degrees F. Bathrooms and showers were textured and equipped with necessary grab bars, slip resistant strips and built in shower chairs for safety. Apartments contained required furnishings. LPA observed a sufficient supply of perishable and non-perishable foods necessary for residents in care, along with emergency food and water supply. Residents with special diets posted in kitchen and menus are supplied for residents at each meal with specials each day. Facilities fire extinguishers were inspected 08/05/2025. Facility smoke and carbon monoxide detectors tested by Fire Inspector on 07/03/2025. Fire Sprinkler system tested 11/11/2025. Facility has commercial generator for electrical emergencies. Facility’s First Aid Kits were sufficient. Facility has medication room and two medication carts, one for each side of facility. There is an RN and an LVN available 24 hours per day, on-cite 16 hours per day. Facility utilizes a call light system. Monthly activity calendar posted throughout facility, that includes 5 days of interactive entertainment; morning exercise, music, holiday craft making, dessert making, outings once a week. Continue on LIC809-C Continued from LI809 Required posters for Long Term Care Ombudsman and Complaints were located in each (2) dining/common room areas, across from staff break room and in lobby. Egress doors on all 4 exits accessible to residents have audible alarms when doors are opened without access codes. Doors tested during today’s inspection working properly, with staff responding appropriately. Emergency disaster drills are conducted monthly during different shifts with the last conducted on 10/08/2025. Toxins secured in numerous storage rooms inaccessible to residents in care. Component III was reviewed with Administrator. No Deficiencies or Advisories given during visit. Pre-Licensing completed. Facility is ready to be Licensed as a Residential Care Facility for the Elderly. Facility to follow up with CAB regarding Hospice Waiver. LPA will submit TSP referral for future Administrator LPA will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Analyst will notify Applicant of Status. LPA will conduct medication review and file review at Post-Licensing inspection. Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Nov 13, 2025

Type of visit: Office

COMP II by CAB successfully completed Method: Phone Call at CAB Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Sep 24, 2025