Rose Garden Residential Care

Allegation investigated: Staff mismanaged resident's medication

Licensing Program Analyst (LPA) E.Conchas made an unannounced visit to the facility to conduct complaint investigation for the allegation stated above. LPA met with Administrator, Melissa Buckridge and explained the reason for the visit. During today's visit, LPA conducted interviews with staff, residents, a witness, as well as reviewed pertinent documents. Based on the allegation that staff mismanaged medication, three of four residents reported they do receive their medications from staff. Two of four residents stated that staff have not missed their medications or given incorrect medications. One witness reported having no issues or concerns regarding their family member receiving medications from staff. Continue to LIC 9099-C Unsubstantiated Interview with S2 stated R1 would pocket or spit out food, but at times R1 would still take their medication. S3 interview stated R1 began refusing or pocketing food approximately one week prior to transitioning towards end of life. S4 stated that although R1 was sometimes not eating, the medication was small enough to be crushed and given in a spoonful, though at times R1 would drool it out. LPA reviewed R1’s medication records and physician orders. Facility documentation reflected a mechanical soft diet with thin liquids and an order for crushed medications, while hospice records reflected a physician order for a puree diet. Due to limited staff notes, LPA was unable to verify all dates of medication administration. Based on record review and interviews, the allegations that staff mismanaged medications is Unsubstantiated. Unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted were this report was discussed and a copy provided to Administrator, Melissa Buckridgethe state’s words, verbatim · CDSS document, Apr 29, 2026 · control 56-AS-20260226163653

Allegation investigated: Resident sustained fractures while in care

On 4/15/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering the complaint investigative findings into the allegation listed above. LPA Flores met with Executive Director Melissa Buckridge, and explained the purpose of the visit. The investigation is summarized as follows: Information received alleged Resident #1 (R1) sustained fractures while in care. An interview conducted with Staff #1 (S1) reports that R1 eloped from the facility some time after 10PM when R1 was last seen. Staff at the facility were unaware of R1’s absence until Law Enforcement arrived at approximately 1:00 AM the following morning requesting if R1 was currently residing at the licensed facility. S1 was made aware of the incident by staff at the facility. Interviews with Staff #2 (S2) and Staff #3 (S3) corroborate S1’s account, reporting that staff were made of R1’s elopement as a deputy from the local Law Enforcement arrived at the facility to confirm if R1 was residing at the facility. (Continue to LIC9099C) Substantiated (Continuation from LIC9099A) It was alleged that the family wished to terminate their agreement with the facility as the out-of-pocket price was higher than what they could afford at the time. S1 declined the allegation of facility staff unlawfully evicting R1. LPA attempted to speak with R1 and their responsible person, but attempts were unsuccessful. LPA attempted to speak with the insurance provider but were informed that there were no records of who the prior case manager was. Therefore, the allegation of illegal eviction is deemed unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted and a copy of this report was provided to the Executive Director. (Continuation from LIC9099C) Staff were informed that R1 sustained multiple injuries from a fall on the curb and were transported to the hospital. Interviews with S3 report that an unknown staff from the previous shift had left a note behind warning the next shift that R1 was at risk of elopement. Records review reported that R1 was admitted into the facility on 5/26/2021. A physicians report dated 5/21/2021, reports that R1 was unable to leave the facility unassisted and is known to be a fall risk. As a result of R1’s elopement, R1 sustained multiple injuries from a fall that occurred outside of the facility. Therefore, the allegation of resident sustained fractures while in care are deemed substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. California Code of Regulations Title 22 is being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of the LIC9099, LIC9099C, LIC 9099D, and appeal rights were reviewed and provided to the Executive Director.the state’s words, verbatim · CDSS document, Apr 15, 2026 · control 18-AS-20210616115655

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.2(c) · Plan of correction due date: May 1, 2026

(c) “Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement was not met with evidence by: (1) one out of (1) one resident eloped from the facility without staff knowledge resulting to Resident #1 (R1) sustaining multiple injuries.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Executive Director agreed to conduct an in-service training with staff in regard to how frequent health and safety checks shoulf be done. Proof of training will be submitted to LPA via email by close of business on 5/1/2026.

Allegation investigated: Staff chemically restrained resident

On 3/30/2026, Licensing Program Analyst (LPA) Edith Conchas conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Administrator Melissa Buckridge and explained the purpose of the visit. Staff chemically restrained resident The investigation consisted of interviews with staff and review of pertinent documents. LPA reviewed S7 file and observed a final disciplinary warning document dated 9/25/2025, which states S7 was in misconduct by using or possessing drugs on company premises and a medication error. In addition, LPA observed that on 9/25/2025 S7 was terminated from employment due to staff reporting observing S7 with cannabis in personal possession. Continue to LIC 9099-C Substantiated LPA conducted five (5) staff interviews and interviews revealed that S7 no longer works at the facility. Interview with S4 revealed that S7 disclosed to S4 giving a THC drink to R1. S4 and S5 stated they observed R1 appearing “out of it” shortly after S7 reported providing the THC drink. LPA was unable to interview R1, R1 passed on 11/15/2025. Based on LPA’s observations, record review, and interviews that were conducted, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 6 are being cited on the attached LIC 9099-D. An exit interview was conducted, and a copy of this report was provided to the Facility Administrator, Melissa Buckridge.the state’s words, verbatim · CDSS document, Mar 30, 2026 · control 56-AS-20250911124320

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.625(c)(7) · Plan of correction due date: Mar 31, 2026

(7) Dementia care, including the use and misuse of antipsychotics, the interaction of drugs commonly used by the elderly, and the adverse effects of psychotropic drugs for use in controlling the behavior of persons with dementia. This requirement is not met as evidenced by: Based on LPA's record review and interviews, staff 7 was observed having and using canabis susbtance while working at facility which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 30, 2026

Plan of correction: Staff 7 was terminated on 9/25/2025. Administrator will conduct a staff training on Health and safety regulation 1569.625(c) (7) Adminsitrator will provide a copy of the training topic and sign in sheet upon completion to LPA via email on or by 4/08/2026.

Type of visit: Case Management - Other

On 3/24/2026, Licensing Program Analyst (LPA) E. Conchas made an unannounced visit to the facility to initiate a complaint investigation for complaint numbers 56-AS-20250804105457 and 56-AS-20250911124320. LPA met with Melissa Buckridge, Administrator and explained the reason for the visit. During today's visit LPA observed pertinent documents and conducted staff interviews. LPA will need to complete follow-up telephone calls and/or visits before reaching investigative findings. Based on observations made, no deficiencies were cited. An exit interview was conducted where this report was discussed and copies were provided to Melissa Buckridge, Administrator.the state’s words, verbatim · CDSS document, Mar 24, 2026

Allegation investigated: Residents sustained injuries due to staff neglect. Staff does not provide adequate supervision to residents in care. Staff leaves residents on the floor for an extended period of time.

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegations. LPA met with Administrtaor Melissa Buckridge, and discussed the purpose of the visit. Regarding allegation #1, LPA interviewed eight (8) residents. Seven (7) residents reported they have neither sustained injuries nor witnessed other residents sustain injuries due to staff neglect. One (1) resident stated they have not experienced any falls and therefore have not sustained injuries. LPA also interviewed six (6) staff members, all of whom stated that residents have not sustained injuries due to staff neglect. Additionally, one (1) staff noted that the residents’ skin are very sensitive, and even minor nicks can result in skin tears. Unsubstantiated Regarding Allegation #2, LPA interviewed eight (8) residents. Five (5) residents reported that there is adequate staff supervision for residents in care, while three (3) residents stated that staff supervision is insufficient. LPA interviewed six (6) staff members, all of whom confirmed that there are adequate staffing and supervision for residents in care. Regarding Allegation #3, LPA interviewed eight (8) residents. Seven (7) residents stated they have not been left on the floor nor observed other residents being left on the floor for an extended period. One (1) resident reported witnessing a resident left on the floor for an extended period. LPA interviewed six (6) staff members, all of whom stated that residents are not left on the floor for extended periods. Staff explained that they respond immediately after a fall; however, some residents require evaluation prior to being assisted to ensure their safety. Based on LPA’s observations, interviews, and relevant documentation, the allegations are determined to be Unsubstantiated. An Unsubstantiated finding means that although the allegations may be valid or could have occurred, there is insufficient evidence to support that the alleged violations did or did not happen. An exit interview was conducted with Administrator Melissa Buckridge, and a copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 56-AS-20240613094612

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) E. Conchas made an unannounced visit to the facility to deliver two (2) complaint investigation deficiencies on complaint 56-AS-20251205105836. LPA met with Melissa Buckridge, Administrator and explained the reason for the visit. During today’s visit, LPA took a tour of the facility and requested copies of pertinent documents. Based on the previous complaints, (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed, and a copy was provided to Melissa Buckridge, Administratorthe state’s words, verbatim · CDSS document, Feb 3, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87775(b)(8) · Plan of correction due date: Mar 3, 2026

87555General FoodServiceRequirements (b)(8)All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged...shall not be accepted, used or retained. This requirement is not met as evidenced by: staff did not inspect the food to ensure the food service was in a quality condition for the client/resident in care which poses a potential health, safety and personnal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Administrator will create a food log inspection form and have staff inspect the food qaulity prior to receving it from 3rd party vendor. Adminsitor wil provide a copy of the template to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR80092.1(n) · Plan of correction due date: Mar 3, 2026

80092.1 General Requirements for Restricted Health Conditions (n)The licensee shall ensure that the client’s health-related service needs are met and shall follow the approved plan for each client. This requirement is not met as evidenced by: Staff did not seek medical attention for resident in care after an unwitnessed fall which poses a potential health, safety and personnal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Administrator has added an additional staff to solely observe clients in care during dinning and activites to assit with fall risk observation and report.

Allegation investigated: Questionable death Staff did not assist resident with incontinence care Resident sustained bruises while in care

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to deliver findings on the allegation mentioned. LPA met with Executive Director Melissa Buckridge and explained the purpose of the visit. The Department's investigation involved interviews and records review. Regarding allegation #1, Department staff conducted an investigation which revealed. On the evening of 02/18/2024, resident #1 (R1) was found on the floor in their room by facility staff, positioned near the bed. It was presumed R1 fell from the bed. When asked by staff, R1 was unable to explain what happened but stated to be ok. Staff observed a golf ball-sized bump on R1’s forehead and immediately called 911. R1 was transported to the hospital emergency room, where diagnostic imaging revealed multiple injuries, including a closed fracture of multiple ribs on the left side, a displaced fracture of the right clavicle, and a subdural hematoma. R1 remained hospitalized and passed away on 02/27/2024. Interviews with facility staff and outside parties confirmed that R1 had no prior falls at the facility and there were no reports or documentation of R1 being dropped during transfers. Unsubstantiated Department staff were provided with documentation of care and supervision consistent with R1’s needs. Based on the investigation, there is no evidence that R1’s death resulted from neglect or lack of care and supervision by facility staff. Regarding allegation #2, LPA conducted interviews with residents and staff. Interviews were conducted with six (6) residents. Two (2) residents reported they do not require assistance with incontinence care. Two (2) residents stated that staff provide incontinence care assistance in a timely manner. One (1) resident was unable to confirm whether staff assist with incontinence care. Interviews with two (2) staff members indicated that they assist residents with incontinence care promptly. One (1) staff member noted that residents requiring incontinence care assistance are typically non-verbal. Allegation #3, Resident sustained bruises while in care. It was reported that R1 was observed with a bruise on the arm believed to resemble a handprint. Photos of the bruise were observed by Department staff. The images did not appear to show a hand shaped mark. It was reported that staff in the facility caused the bruise grabbing R1’s arm and later throwing R1 on the bed. Interviews with facility staff and other residents did not reveal any evidence or witness to corroborate physical abuse by facility staff. Based on the investigation, there is no evidence to support the allegation of physical abuse. Based on the information gathered, the allegations were determined to be UNSUBSTANTIATED. An Unsubstantiated complaint means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Executive Director Melissa Buckridge and a copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 56-AS-20240322114507

Allegation investigated: Neglect/Lack of care and supervision resulting in resident hospitalization.

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to deliver findings on the allegation mentioned. LPA met with Executive Director Melissa Buckridge and explained the purpose of the visit. The Department's investigation involved interviews and records review. It is alleged Neglect/Lack of care and supervision resulted in resident hospitalization. Resident #1 (R1) denied receiving any medication or substance that was not prescribed to them. Medical records show that on December 31, 2023, a urinalysis was positive for fentanyl but negative for norfentanyl and other opioids. The medical report concluded that R1’s confusion was most likely related to their underlying diagnosis, potentially worsened by dehydration and elevated glucose levels. Facility staff denied any on the premises and denied providing it to R1 or having any knowledge of how R1 could have been exposed. Residents interviewed also reported no concerns regarding staff use, possession, or distribution of fentanyl and expressed no concerns about neglect or inadequate care. Unsubstantiated The investigation found insufficient evidence to substantiate allegations of neglect or lack of care. The allegation is therefore deemed unsubstantiated. An Unsubstantiated complaint means, that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Executive Director Melissa Buckridge and a copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 56-AS-20240104104232

Allegation investigated: Resident sustained multiple injuries while in care. Staff fail to seek timely medical attention for resident in care.

Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Administrator Schamone Bard and explained the purpose of the visit. The investigation consisted of resident and staff interviews. For the allegation, Resident sustained multiple injuries while in care. LPA conducted (3) staff interviews. 3 out of the 3 staff stated they do not recall injuries occurring. Additionally, 3 out of the 3 staff stated if any injuries occurred medical services will be initatied. LPA conducted (2) resident interviews. 2 out of the 2 residents stated they do not recall any resident receiving multiple injuries while in care. Resident #2 (R2) stated facility staff did assist residents in the event an injury occurred. For the allegation, Staff fail to seek timely medical attention for resident in care. LPA conducted (3) staff interviews. 3 out of the 3 staff stated facility staff did seek medical attention in a timely manner for residents during this time. LPA conducted (2) resident interviews. 2 out of the 2 residents stated in the event of an emergency, facility staff did seek medical attention for residents in a timely manner during this time. Unsubstantiated Based on the evidence gathered during today’s investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. During today’s visit pertaining to the allegations listed, no deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Schamone Bard.the state’s words, verbatim · CDSS document, Dec 23, 2025 · control 56-AS-20230530155654

Allegation investigated: Staff do not ensure that resident's responsible party is notified of changes in condition. Staff do not respond to calls from resident's representative in a timely manner. Staff do not respond to resident's calls for assistance.

Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Schamone Bared and explained the purpose of the visit regarding the allegations listed above. First allegation: Staff do not ensure that resident's responsible party is notified of changes in condition. Regarding the allegation stated above, LPA conducted an interview with S#1 LPA went over the alleged allegation with S#1 and S#1 informed LPA that the facility will inform R#1 responsible party/and or conservator regarding the changes or incidents involving R#. LPA collected all documentation along with special incident reports involving R#1 during review of records (Special incident reports) LPA discovered that the facility would notify R#1 responsible party of the incidents involving R#1. In addition, records also showed that the facility was also notifying the appropriate agencies regarding incidents involving R#1. LPA conducted interviews with Residents #2-4 LPA went over the alleged allegation with the residents and all informed LPA that they have no concerns regarding the facility not communicating incidents that involve residents change of condition to residents’ responsible party. Unsubstantiated In addition, during record review LPA observed that R#1 was admitted to Rose Gardens on 3/15/2024, during R#1 admission R#1 did not have a responsible party appointed. During further review, LPA observed that a conservator was appointed to R#1 on 10/6/2025. Second allegation: Staff do not respond to calls from resident's representative in a timely manner. Regarding the allegation stated above, LPA conducted an interview with S#1 regarding the alleged allegation S#1 informed LPA that all calls involving R#1 were returned back to the responsible party. In addition, S#1 informed LPA that the facility encountered issues locating or reaching a responsible party for R#1 and the facility appointed R#1 to a public guardian/Conservator that would manage the financial and responsibility for R#1. LPA conducted interviews with R#2-4 LPA went over the allegation with the residents and all informed not having concerns regarding facility not returning or responding to calls. LPA conducted interviews with S#2-3 concerning the alleged allegation and all denied the allegation regarding staff not responding to calls from resident[s] representatives. Third allegation: Staff do not respond to resident's calls for assistance. Regarding the allegation stated above, LPA conducted a walkthrough of the facility LPA observed a call system to be in place inside the Med-Tech office. LPA inspected the call system and observed that a few lights were down the Maintenance Director informed LPA that the facility had an annual inspection on 12/5/2025 and were issued a deficiency with a Plan of Correction. Maintenance director informed LPA that the facility has already implemented a work order and the call system is currently being worked on. LPA conducted interviews with R#2-4 LPA went over the alleged allegation with the residents and all informed LPA that the wait time for assistance many vary however, they receive the assistance on time. LPA conducted interviews with S#2-4 regarding the alleged allegation and all denied not responding to residents calls on a timely manner. Based on corroborating evidence the department has determined that the above allegations are Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Schamone.the state’s words, verbatim · CDSS document, Dec 19, 2025 · control 56-AS-20250114083545

Allegation investigated: Staff leave resident in soiled diapers/clothes Staff are not following special diet physicians order Staff are not assisting resident with feeding/drinking

Licensing Program Analyst (LPA) Becky Mann conducted an unannounced visit to the facility to initiate a complaint investigation. LPA Mann met with Schamone Bard, Executive Director and explained the purpose of today's visit.The investigation consisted of observations, record reviews, interviews with staff, and residents. The allegation that staff leave resident in soiled diapers/clothes. Four (4) staff interviewed stated that they have not left residents in soiled diapers and/or clothes. The four (4) staff have not seen another staff leave a resident in soiled diapers and/or clothes. LPA interviewed five (5) residents, they were not able to answer due to cognitive impairment. LPA was unable to interview Resident #1 (R1) due to no longer residing at the facility. Based on LPA observations and record reviews, R1 does not reside at the facility anymore. Based on LPA observations, residents are kept clean and dry. Residents are assisted with diaper change or clothes change when needed. Unsubstantiated The allegation that staff are not following special diet physicians order. Four (4) staff interviewed stated that they do follow the special diets based on physicians order. Five (5) residents interviewed were not able to answer due to cognitive impairment. LPA toured the facility and observed in the kitchen area that there was a special dietary binder for residents who are on a special dietary plan. Based on LPA observations, interviews and record reviews, staff do follow the special dietary plans for residents. The allegation that staff are not assisting resident with feeding/drinking. Four (4) staff interviewed stated that they do assist the residents with feeding and drinking. Five (5) residents interviewed were not able to answer due to cognitive impairment. During the facility tour, LPA observe staff assisting the resident with eating and drinking. Based on evidence obtained during the investigation, the above allegations are Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed, and a copy was provided to Schamone Bard, Executive Director at the conclusion of the visit.the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 56-AS-20240103084422

Allegation investigated: Resident sustained an injury as a result of a unwitnessed fall Staff did not seek medical attention for residents in care Staff does not ensure food served is of good quality Staff does not ensure expired food is discarded from the facility

On 12/12/2025, Licensing Program Analysts (LPA) Edith Conchas conducted an unannounced complaint visit to the property in order to initiate an investigation into the above allegation. The LPA met and discussed the purpose of the visit with Executive Director, Schamone Bard. The investigation consisted of interviews with the operator, staff and witnesses. Reagarding allegation the Resident sustained an injury as a result of a unwitnessed fall, interview with witness 1 (W1) reveal resident 1(R1) fell and hit his head. Regarding the allegation Staff did not seek medical attention for residents in care, LPA interviewed 6 staff and confirmed resident did fall and did not seek medical attention only sat him back up on the chair. Regarding allegation Staff does not ensure food served is of good quality, interview with staff 2 (S2) reveal mold was observed in the bread. Regarding allegation Staff does not ensure expired food is discarded from the facility, intreview with staff 2 (S2) reveal the mold was observed on the bread after serving it to the resident. Continue LIC 9099-C Substantiated Based on interviews, and record review, the allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. During today’s visit, deficiency and a repeated violation civil penalty was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report LIC9099, LIC9099C, LIC9099D, LIC421FC and appeal rights were discussed and provided to Executive Director, Schamone Bardthe state’s words, verbatim · CDSS document, Dec 12, 2025 · control 56-AS-20251205105836

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Dec 15, 2025

87465 Incidental Medical and Dental Care(g) (g) The licensee shall immediately telephone ...a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cite above by not calling 911 after falls with suspected head injury for R1 which poses an immediatel health, safety and personnal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 12, 2025

Plan of correction: Administrator will create a log book on designated hall person daily for all shifts to ensure observation is being done for patients safety and provide a copy to LPA by POC date and will conduct an in-service training with all staff on reporting unwitnessed falls and seeking medical attention.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Dec 15, 2025

87555General Food Service Requirements(a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs and... shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cite above by not serving mold to a resident. Which poses an potential health, safety and personnal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 12, 2025

Plan of correction: Administrator will create a log book for daily inspection of food upon arrrival of shift for cooks to complete daily and provide a copy to LPA by POC and will provide in-service training on food handling

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) E. Conchas made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Executive Director Schamone Bard assisted with the overall inspection of the facility which included, but was not limited to the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL) There are no pools or other bodies of water located on the premises. There are no firearms or ammunition kept at the facility. The facility is maintained at a comfortable temperature at 77 degrees throughout the living quarters of the residents. The outdoor and indoor passageways are kept free of obstruction. The hot water temperature was measured which measured at 107 degrees. There are grab bars for each toilet, bathtub and shower used by residents. Smoke detectors and carbon monoxide devices were observed and tested. Fire extinguishers were fully charged and their last drill was on 11/4/2025. Emergency drills were observed completed but not in a quarterly manner a technical assistance was issued. LPA observed some bathrooms not having non-skid mats. A technical assistance was issued. Care and Supervision: The facility appears to have enough staff members to care for the residents needs 24/7. Record Review: LPA reviewed residents files for admission agreements, updated physician reports. Medication Administration Records (MAR’s) appeared to not be administered as prescribed by their physicians. A deficiency was cited. LPA also reviewed staff files for First Aid/CPR certification, training's, and health screenings and the files appeared to be current. Based on the observations made during today’s visit two deficiencies were cited and two technical assistance. An exit interview was conducted, and this report was discussed and provided to Executive director Schamone Bard at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Dec 5, 2025

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Licensee does not ensure that staff follow proper infection control protocols.

On 10/1/2025, Licensing Program Analysts (LPA) Edith Conchas and Sarina Ramirez conducted an unannounced visit to conduct an investigation on the allegations listed above. LPAs met with Facility Administrator Shamone Bard and explained the purpose of the visit. First Allegation: Licensee does not ensure that staff follow proper infection control protocols. During the investigation, LPAs Observed pertinent records, the current infection control plan was not updated and No In-service training for Infection control on Covid-19. LPAs conducted Four (4) staff interviews and five (5) residents interviews. In addition LPA took a tour of the facility with the Administrator Shamone and were able to obtain sufficient evidence to corroborate the allegation. Two (2) out of four (4) staff stated the PPE procedures can be more strictly enforced due to witnessing other staff not following procedures. Substantiated One (1) of the four (4) staff informed LPA the first days of residents testing positive there was not enough PPE supplies. LPAs observed in three(3) storage areas there were individual boxes of gloves, boxes of gowns, N95 masks but no supply of surgical masks available. Administrator informed LPAs due to providing masks to resident's family, and no longer having positive covid-19 residents; the supply is now low. Based on LPAs observations, record review and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 6 & Chapter 6, are being cited on the attached LIC 9099D Therefore, the allegations that; Licensee does not ensure that staff follow proper infection control protocols was found to be SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted, and a copy of this report LIC9099,LIC9099C, LIC9099D was provided to the Licensee Shamone Bard.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 56-AS-20250923125605

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(c) · Plan of correction due date: Oct 15, 2025

87470 Infection Control Requirements (c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by: Based on LPAs record review, observation and interviews Licesnee did not have an updated Infection control plan nor an infection control training completed on Covid -19 use of Personal Protective equiptment (PPE). This poses a potential risk to the health safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 1, 2025

Plan of correction: Administrator will provide updated Infection control plan and procedure and will conduct in In-service training on Infection Control guidelines and procedures on communicable diseases by POC due date.

Allegation investigated: Staff do not properly maintain the facility Staff mishandled a resident's personal belongings Staff do not have adequate record keeping for a resident

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Business Office Manager Michelle Reyes and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records. First allegation: Staff do not properly maintain the facility. Regarding the first allegation pertaining to “Staff do not properly maintain the facility” on 3/13/2024 LPA conducted an inspection inside cottage B of the facility LPA observed first room to be in despair LPA was informed by facility maintenance manager that facility is in the process of conducting repairs. In addition, during the inspection in cottage B LPA observed bathroom to be unsanitary, LPA observed a soiled diaper and paper towels to be laying on the bathroom floor. Second allegation: Staff mishandled a resident's personal belongings. Regarding the allegation stated above LPA requested documentation pertaining to Resident #1 during record review LPA observed that R#1 did not have an inventory sheet listing R#1 personal property. Substantiated In addition, based on R#1 admission agreement LPA observed facility to have a theft and loss program, which indicated that facility maintain a theft and loss policy. During further review LPA observed that R#1 did not have a theft and loss policy on file. Third allegation: Staff do not have adequate record keeping for a resident. Regarding the allegation stated above LPA collected documentation pertaining Resident #1 during record review LPA discovered that R#1 inventory form was missing in addition, LPA also discovered that R#1 theft and policy form was also missing and not to be found. Based on review of records and evidence gathered the above allegations are Substantiated. Substantiated: A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Maintenance and Operation 87303(a), Theft and Loss 87218(a)(1)(2), Resident Records 87506(a)(1), from division 6, chapter, article 6, is being cited on the attached LIC 9099 D. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights to Facility Business Office Manager Michelle Reyes. the (L unit). LPA collected activity calendars. On 8/8/2025 LPA conducted a follow-up inspection and observed that activity room is still located in (L unit), LPA observed residents playing bingo. In addition, LPA collected an activity calendar for the month of August. Third allegation: Staff did not provide comfortable accommodations for a resident. Regarding the allegation stated above LPA conducted interviews with Residents 1-3 regarding the allegation “staff did not provide comfortable accommodations for a resident” all residents informed LPA that they have no issues to report regarding the allegation and feel that their accommodations are being met by staff. LPA conducted a walkthrough of the facility and observed units to have a working AC, LPA observed all rooms to be cool/and fresh. LPA conducted interviews with Staff 2-4 and all staff informed LPA that all residents receive comfortable accommodations. In addition, Staff #3 informed LPA that facility has water available in dining area. Furthermore, S#3 informed LPA that during round checks caregivers provide water to residents daily. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated. Unsubstantiated: meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Business Office Manager Michelle Reyes at the end of the visit.the state’s words, verbatim · CDSS document, Aug 8, 2025 · control 56-AS-20240308092901

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 15, 2025

Maintenance and Operation... (a) the facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: Based on observation, facility did not follow maintenance and operation regulation to keep facility clean, sanitary and in good repair for 1 out of 4 units, which poses a potential health, safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: Licensee has agreed to read over the Maintenance and Operation regulation and provide training to all staff. Administrator will provide a copy of the training that is signed and dated by staff to LPA on POC date 8/15/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a)(1)(2) · Plan of correction due date: Aug 15, 2025

Theft and Loss 87218.... (a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153.... (1) The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative.... (2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. The licensee shall be presumed to have made reasonable efforts to safeguard resident property if there is clear and convincing evidence of efforts to meet each requirement specified in Section 1569.153. This requirement is not met as evidence by: Based on record review, facility did not follow theft & loss regulation for Resident#1 leading to R#1 loss and mismanagement of R#1 personal belongings, which poses a potential health, safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: Licensee has agreed to read over the Theft and Loss regulation and provide training to all support staff on how to properly record resident’s personal belongings. Licensee will provide a copy of training that is signed and dated by staff to LPA on POC date 8/15/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a)(1) · Plan of correction due date: Aug 15, 2025

87506 Resident Records....(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.....(1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not follow title 22 regulation pertaining to “resident records” by not storing active and inactive records and not safeguarding R#1 records, which poses a potential health, safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: Licensee has agreed to read over the regulation and provide training on regulation “87506 Resident Records” Licensee will email LPA a copy of the training signed and acknowledge by all staff by POC date 8/15/25.

Allegation investigated: The facility is violating the approved fire capacity. Staff is mismanaging residents medications. Resident's care needs are not being met.

On 5/16/2025 at 12:10 PM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to deliver the findings of the above allegations. LPA Serrano met with Executive Director Schamone Bard to explain the purpose of the visit. The investigation consisted of file review, interviews with facility staffs and residents as well as facility observation. Allegation #1: The facility is violating the approved fire capacity. – Based on observation, interview and file review, the facility never goes over the capacity of 63 residents. Based on the interview with Staff #1 (S1) the maximum residents that the facility ever had was 56 in total. Information received during the investigation; LPA was unable to corroborate the allegation *** Continuation in LIC9099C *** Unsubstantiated Allegation #2: Staff is mismanaging residents medications. - Based on interviews, 3 out 3 residents stated that they are getting their medications on time and does not know any staff that was mismanaging any medication. Based on record review of their electronic medication administration record (EMAR), LPA observed that the medications were administered on time and no issues. Information received during the investigation: LPA was unable to corroborate the allegation. Allegation #3 Resident's care needs are not being met. - Based on interviews, 3 out of 3 residents stated that their care needs are being met, and they are being treated well. information received during the investigation did not corroborate with the allegation. Additional interviews with witnesses and the alleged victim were unable to be conducted at this time due to unavailability. During the investigation, LPA did not find evidence to corroborate the allegations. Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted where this report, LIC9099 and LIC9099C were discussed and provided to Executive Director Schamone Bard.the state’s words, verbatim · CDSS document, May 16, 2025 · control 56-AS-20231229131955

Allegation investigated: Staff did not provide responsible party with resident's records in a timely manner

Licensing Program Analyst (LPA) Becky Mann conducted an unannounced visit to the facility to initiate a complaint investigation. LPA Mann met with Michelle Reyes, Business Office Manager and explained the purpose of today's visit. The investigation consisted of LPA observations, pertinent document reviews, and interviews with staff. The allegation staff did not provide responsible party with resident’s records in a timely manner. LPA Mann interviewed Staff #1 (S1) and stated that at this time they are still unable to retrieve resident's records to provide to responsible party. Based on LPA observations, interviews and records review, the above allegation is Substantiated. A determination that the complaint is substantiated means that the allegation is/are valid because the preponderance of the evidence standard has been met. An exit interview was conducted where this report was discussed and provided to Michelle Reyes, Business Office Manager. Substantiatedthe state’s words, verbatim · CDSS document, Apr 8, 2025 · control 56-AS-20250402130532

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Apr 15, 2025

‘residents in privately operated residential care facilities for the elderly shall have all .. personal rights:’ ... ‘(19) To have prompt access to review all of their records ... Photocopied records shall be provided within two (2) business days... This requirement is not met as evidenced by: Based on LPA observations and interviews, staff was not able to provide responsible party with resident's records in a timely manner which poses a personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Apr 8, 2025

Plan of correction: Business Office Manager will submit resident's records to responsible party by Plan of Correction (POC) due date and send LPA confirmation of submission by email

Allegation investigated: Staff did not ensure care needs of resident were being met

Licensing Program Analyst (LPA) Becky Mann conducted an unannounced visit to the facility to initiate a complaint investigation. LPA Mann met with Schamone Bard, Executive Director and explained the purpose of the visit. The investigation consisted of LPA observations, record reviews, interviews with staff and residents. The allegation that staff did not ensure care needs of resident were being met. The five (5) residents interviewed stated that the staff does ensure the care needs of residents are being met. The seven (7) staff interviewed stated that they do ensure the care needs of the residents are being met. Based on the evidence obtained during the investigation, the above allegations are Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report LIC9099 was discussed and provided to Schamone Bard, Executive Director. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 26, 2025 · control 56-AS-20250220091434

Allegation investigated: Staff do not intervene between residents who are behaving aggressively. Administrator is not on the premises a sufficient number of hours to permit adequate attention to the facility. Staff do not properly maintain the facility. Licensee does not ensure facility is adequately staffed to meet residents needs

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility to initiate a complaint investigation and deliver the findings. LPA Allen met with Administrator Schmone Bard who was informed of the purpose of the visit and the allegations. The investigation consisted of interviews with staff and residents , as well as a tour of the facility, both inside and out. During the visit, LPA Allen interviewed staff members and residents who acknowledged occasional instances of aggression between clients, but staff members intervene promptly and redirect the clients. Staff also confirmed that an acting Administrator had visited the facility previously, and a new Administrator has been in place since January 8, 2025. LPA Allen noted that the facility was clean, free of debris and odors. Additionally, LPA observed that there was enough food, including a 7-day supply of non-perishable items and a 5-day supply of perishable items for the residents in care. Unsubstantiated The staff interviews revealed that there are occasional challenges due to staff callouts, but other staff members are called in to cover shifts as needed. LPA Allen observed a staff schedule dated January 14, 2025, which indicated that there is sufficient staff available to care for the residents. Based on the evidence gathered during the investigation, the above allegation is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed and provided to Shamone Bard- Administrator at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Jan 14, 2025 · control 56-AS-20250106091955

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Michelle Reyes- Business Office Manager who informed LPA Yehuda Cohan is the acting administrator until the new administrator starts January 1,2025. Michelle assisted with the overall inspection of the facility which included, but was not limited to the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL) There are no pools or other bodies of water located on the premises. There are no firearms or ammunition kept at the facility. The facility is maintained at a comfortable temperature between 72-75 degrees throughout the living quarters of the residents. The outdoor and indoor passageways are kept free of obstruction. The hot water temperature was measured throughout the facility which measured between 102-124 degrees. There are grab bars for each toilet, bathtub and shower used by residents. Smoke detectors and carbon monoxide devices were tested and found to be in working order. the fire extinguishers were fully charged and their last drill was on 12/13/2024. Food Service: There is a verity and a sufficient amount of nonperishable and perishable foods items available for the residents in care. Care and Supervision: The facility appears to have enough staff members to care for the residents needs 24/7. Record Review: LPA reviewed four (4) residents files for admission agreements, updated physician reports, and Medication Administration Records (MAR’s) which appeared to be administered as prescribed by their physicians. LPA also reviewed four (4) staff files for First Aid/CPR certification, training's, and health screenings and the files appeared to be current. Based on the observations made during today’s visit, no deficiencies were cited. An exit interview was conducted, and this report was discussed and provided to Michelle Reyes- Business Office Manager at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Dec 30, 2024

Allegation investigated: Staff did not provide records to resident's authorized person.

Licensing Program Analyst (LPA) Bernadette Allen met with Business Office Manager Michelle Reyes at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office on 12/23/2024 at 8:00 AM to deliver the findings of the above allegation. LPA Allen explained the purpose of the requested office visit. The investigation consisted of interviews with Administrator Celia Garcia and the authorized representative of Resident 1 (R1). Both stated that the requested documents available at the time of the request were forwarded to Resident 1's authorized representative on August 16, 2024. LPA Allen also reviewed documents confirming that the records were provided on August 16, 2024, as requested. Based on interviews and evidence gathered during the investigation, the above allegation is found to be Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Unfounded An exit interview was conducted where this report was discussed and provided to Business Office Manager Michelle Reyes at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 56-AS-20241101122704

Allegation investigated: Facility does not have adequate staffing to meet the needs of the residents in care. Facility has bed bugs.

Licensing Program Analyst (LPA) Bernadette Allen met with Business Office Manager Michelle Reyes at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office on 12/23/2024 at 8:00 AM to deliver the findings of the above allegations. LPA Allen explained the purpose of the requested office visit. The investigation involved interviews with staff, residents, responsible parties, and a review of records. Interviews with facility staff and responsible parties revealed that while staffing may have been a concern in the past, there has recently been sufficient staff to care for the residents. LPA attempted to interview residents about the presence of bed bugs in their living quarters, but they were unable to confirm or deny having bed bugs in their rooms. Responsible parties of the residents were asked if they had been notified about the bed bug issue, and they all confirmed that they were informed and that a pest control company had addressed the problem. LPA Allen was also provided with a copy of the pest control contract, confirming that immediate action was taken to resolve the issue. Unsubstantiated Based on the evidence gathered during the investigation, the above allegations are found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed and provided to Business Office Manager MIchelle Reyes at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 56-AS-20240918162942

Allegation investigated: Staff did not alert the residents of the change in the license. Staff is yelling at the residents.

Licensing Program Analyst (LPA) Bernadette Allen met with Business Office Manager Michelle Reyes at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office on 12/23/2024 at 8:00 AM to deliver the findings of the above allegations. LPA Allen explained the purpose of the requested office visit. The investigation involved interviews with staff members, residents, responsible parties, and a review of records. Staff interviews revealed that there were informal discussions about the facility being sold to another company prior to the official notification of the change in ownership. However, staff were later formally notified at the facility, and about two weeks after that, a written notice was mailed to both staff and residents' responsible parties. LPA also reviewed a copy of the letter notifying individuals of the change in facility ownership. Unsubstantiated LPA attempted to interview residents in care, but they were not able to confirm or deny the allegation of staff yelling at them. Additionally, the responsible parties of the residents were asked if they or their family members had ever experienced or heard of staff members yelling at them, and they all stated no. Based on the evidence gathered during the investigation, the above allegation is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed and provided to Michelle Reyes at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 56-AS-20241003123839

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced case management visit to interview residents, staff, and obtain additional documents for the complaints listed below. LPA met with Business Office Manager Michelle Reyes and informed her of the purpose of the visit. Michelle stated she would have to leave and Wellness Director, Marlene Delgado could sign the report. LPA Allen conducted interviews with staff, residents, responsible parties, obtained additional records, and toured the facility for the following complaints: COMPLAINT CONTROL NUMBER: 56-AS-20241101122704, CONTROL NUMBER: 56-AS-20241003123839, and CONTROL NUMBER: 56-AS-20240918162942. Michelle Reyes was informed that additional time would be required to review the newly obtained information. Before delivering the findings. An exit interview was conducted during which this report was discussed and provided to Marlene Delgado- Wellness Director along with appeal rights.the state’s words, verbatim · CDSS document, Dec 19, 2024

Allegation investigated: Facility staff slapped a resident

Licensing Program Analyst (LPA’s) Bernadette Allen and Becky Mann made an unannounced visit to the facility to conduct a complaint investigation and deliver findings. LPA’s identified themselves and discussed the purpose of the visit and the allegation with Celia Garcia Administrator. The investigation consisted of interviews with staff members, resident, outside parties, and records review. The interview with Resident 1 (R1) stated that a staff member slapped them on their hip for no apparent reason and there were no witnesses around that they could remember. The interviews with the staff members stated that they have not observed any staff members slapping R1 at any time. The interview with the outside party stated that R1 did inform them of the incident with the staff member but they could not confirm of deny if the incident occurred or not. Based on the investigation interviews and documentation, the above findings are Unsubstantiated. Unsubstantiated A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, and a copy was provided to Celia Garcia Administrator at the conclusion of the visit with the appeal rights.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 56-AS-20240827082157

Allegation investigated: Questionable death Lack of supervision resulting in resident falling

Licensing Program Analyst (LPA) Anna Bueno conducted a subsequent visit to deliver findings for the above allegations. LPA met with Executive Director (ED) Ginnie Loekner who was informed of the reason for the visit. LPA Bueno conducted the initial investigation, staff and witness interviews, and records review. Allegation 1: Questionable death. On 1/31/22, the Department received two incident reports on R1 with both incident dates of 1/28/22. The first incident report stated that R1 was found on the sidewalk outside of the dining hall in an apparent fall with bleeding on the right side of their forehead and the second incident reported that R1 was in the local hospital and needed surgery. Staff statements revealed that R1 was found on the ground without any assistive device or any other resident or staff. Documents from emergency medical transport (EMT) state that R1 met the responding crew and with Fire medic. EMT records further state that R1 was monitored with an ECG and continually observed with no changes, no complaints, and no bleeding or shortness of breath, and no nausea. Witness interview confirmed that R1 remained in the hospital from 1/28/22 until their death on 2/9/22. Witness further stated that R1 required emergency brain surgery on 1/28/22 and subsequently suffered Unsubstantiated A finding that the complaint is SUBSTANTIATED means that the allegations are valid as the preponderance of the evidence standard has been met. Refer to LIC809-D for deficiency cited. An exit interview was conducted where this report, LIC809-D, and appeal rights were discussed with and provided to Administrator Loekner. from cardiovascular complications following the surgery. This allegation is therefore unsubstantiated. Allegation 2: Lack of supervision resulting in resident falling. The Department received two incident reports involving R1 on 1/28/22. LPA Fannell reviewed LIC 602 Physician’s report signed on 08/18/21 stating that R1 uses glasses, had no motor impairment or paralysis, and does not use any walking assistive device. LPA reviewed pre-placement appraisal form, LIC 603, completed by family member states that R1 is not able to walk without any physical assistance and R1 will sometimes use a walker but, yes is able to walk with a cane. LPA could not find corroborating evidence that R1 requires assistance or supervision while walking. This complaint is unsubstantiated. Based on the investigation, the above findings are UNSUBSTANTIATED. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where a copy of the entirety report was provided to Administrator Loekner at the conclusion of the visit. reviewed records showing that the facility kept record of payments made by R1’s authorized party and the payment for December 2021 was processed in February 2022. Records show that January 2022 rent has not been paid as of 3/15/2023. This allegation is therefore UNFOUNDED. The Department has found that the allegation is UNFOUNDED meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted where this report was provided to Administrator Loekner.the state’s words, verbatim · CDSS document, Mar 26, 2024 · control 56-AS-20220429162510

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(j) · Plan of correction due date: Apr 2, 2024

87217 Safeguards for Resident Cash, Personal Property, and Valuables (j) Upon the death of a resident, all cash resources, personal property, and valuables of that resident shall immediately be safeguarded. This requirement was not met as evidenced by: Based on records reviewed and interviews conducted, neither staff nor R1's representative were able ro locate R1’s missing antenna.This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 26, 2024

Plan of correction: Licensee agrees to review the regulation cited for safeguard of resident cash, property, and valuables. Licensee shall submit statement of understanding of regulations reviewed by end of POC due date.

Allegation investigated: Staff neglected resident while in care Staff did not meet resident's medical needs Staff did not administer resident's medication as prescribed Staff did not meet resident's hygiene needs

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver findings on the allegations listed above. LPA met with Business Manager Jackie McDonald and Wellness Director Gabriel Salazar and explained the purpose of the visit. The investigation consisted of staff interviews, document reviews, and facility tour. For the allegation, Staff neglected resident while in care. LPA Rico conducted five (5) staff interviews. 5 out of the 5 staff informed they have not neglected the residents while in care. 3 out of the 5 staff members stated they have not witnessed a staff member neglect a resident. During interviews with residents, LPA Rico did not find evidence to corroborate the allegation. For the allegation, Staff did not meet resident's medical needs. Unsubstantiated LPA Rico conducted five (5) staff interviews. 5 out of the 5 staff stated they meet resident’s medical needs. During interviews with residents, LPA Rico did not find evidence to corroborate the allegation. For the allegation, Staff did not administer resident's medication as prescribed. LPA Rico conducted five (5) staff interviews. 5 out of the 5 staff informed LPA residents received their medication as prescribed unless a resident refuses their medication. S1 informed LPA that R1 medication was cancelled through R1 POA. LPA received documentation of cancellation .During interviews with residents, LPA Rico did not find evidence to corroborate the allegation. For the allegation, Staff did not meet resident's hygiene needs. LPA Rico conducted five (5) staff interviews. 5 out of the 5 staff stated they meet resident’s hygiene needs. 4 out of the 5 staff stated they have not witnessed a staff member refused hygiene needs to a resident. During interviews with residents, LPA Rico did not find evidence to corroborate the allegation. Based on the evidence found during the investigation, the four (4) allegation listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to David Monroy VIP Operations along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Mar 1, 2024 · control 56-AS-20231226104943

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to the facility for a complaint 56-AS-20231226104943. During the complaint visit, LPA Rico completed a case management visit to cite for one (1) deficiency found during facility tour. During a facility tour, LPA Rico observed resident’s patio fence door not open and closed properly. When LPA Rico open the fence door, the fence began titling to the side. During today’s visit, one (1) Type A deficiency to the facility were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report, LIC809, LIC809D, Appeal Rights were discussed and provided to David Monroy VIP Operationsthe state’s words, verbatim · CDSS document, Mar 1, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Mar 4, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe and sanitary and in good repair at all times. Maintenance shall include ... This requirement is not met as evidenced by: Based on observations, the Licensee did not comply with the section cited above by having residents patio fence door in disrepair which poses an immediate health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Mar 1, 2024

Plan of correction: Licensee will send LPA proof the patio fence door has been repaired. POC due date 3/4/2024.

Allegation investigated: Staff physical abuse residents Staff did not treat residents with dignity and respect

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conclude a complaint investigation regarding the above allegations. LPA Prieto met with Vice President of Operations Davis Monroy and explained the elements of the complaint. Regarding the allegation of Staff physical abuse residents; LPA interviewed eight residents (R1, R2, R3, R4, R5, R6, R7, R8). None of the resident interviewed express any abuse from staff. In addition, all residents interviewed have not witness any abuse from staff to other residents. LPA interviewed staff #1 (S1, S3, S4, S5), none of the staff interviewed stated that they have been involved in abuse of residents or witnessed other staff abuse residents in care. Facility administrator states that the have ***continued on LIC 9099 *** Unsubstantiated policies in place for reporting and such incidents. LPA Prieto obtained the latest incident reports for our records. None of the incident reports obtained indicated abuse of residents. Regarding the allegation that Staff did not treat residents with dignity and respect; LPA interviewed eight residents (R1, R2, R3, R4, R5, R6, R7, R8). All residents interviewed stated that the staff treat them with dignity and are comfortable with the care being provided. Based on the information obtained there is not enough evidence that staff physical abuse residents and staff did not treat residents with dignity and respect. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Vice President of Operations David Monroy and a copy was left with the facility.the state’s words, verbatim · CDSS document, Jan 30, 2024 · control 56-AS-20231212130733

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced annual required visit. LPA was greeted and granted entry to the facility by Wellness Director Lei Lani Cortez. LPA explained the nature of today's visit. . LPA accompanied with MS Cortez, conducted a general overall inspection, which included, but was not limited to the following: Physical Plant: The facility was not operating over capacity or beyond any conditions and limitations on the license. There are no pools or other bodies of water located on the premises. There are no ammunition or firearms kept in the home. Facility is being maintained at a comfortable temperature for residents. All outdoor and indoor passageways are kept free of obstruction. Hot water temperature was measured at resident bathrooms are within regulation. There are grab bars for each toilet, bathtub and shower used by residents. Smoke detectors and carbon monoxide devices were tested and found to be in working order. Food Service: There is a minimum of one week supply of nonperishable foods and 2 days of perishable foods. Care and Supervision: The facility has ensured sufficient and competent staff to provide the services needed to meet resident needs. Record Review: LPA requested and reviewed (10) resident and (5) staff files. LPA reviewed staff files for current CPR/1st aide certificates, TB results, and required training's. LPA reviewed client files for admissions agreement, physician report, and Needs and Service. Administration: The last fire drill was conducted on 12/21/2023 and the last disaster drill was conducted on 12/21/2023. LPA did not observe any excluded individuals on the premises at time of visit. The Administrator appears to be on the premises a sufficient number of hours to manage and oversee the business operation. Medical Related Services: Prescriptions and non-prescription PRN medications contain a signed and dated written order from a physician. Medications are centrally locked in the staff office and inaccessible to residents in care. Medications are being administered as prescribed by physician's directions. No deficiencies cited. An exit interview was conducted where this report was provided and discussed with MR Monroy.the state’s words, verbatim · CDSS document, Jan 30, 2024

Allegation investigated: Staff left resident unattended in bathtub with running water.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Wellness Director Leilani Cortez and explained the purpose of the visit. The investigation consisted of interviews and review of records. First allegation, Staff left resident unattended in bathtub with running water. During interviews and record review LPA observed that Staff #1 was placed on suspension pending investigation for leaving Resident #1 unattended in bathtub with running water. Documentation indicated that Staff #1 did not get Resident #1 out of the bathtub because Staff #1 needed help and did not want to get shoes wet. Based on the evidence gathered during the investigation, the above allegation is Substantiated. Substantiated A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Personal Rights 80072 (3), from division 6, chapter, article 6, is being cited on the attached LIC 9099 D. Substantiated An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights. to Wellness Director Leilani Cortez at the end of the visit.the state’s words, verbatim · CDSS document, Jan 18, 2024 · control 56-AS-20231221164252

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80072(3) · Plan of correction due date: Jan 19, 2024

1) Personal Rights 80072 (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of punitive nature, including but not limited to: interference with the daily living function, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication, or aids to physical functioning. This requirement is not met as evidence by: Based on interviews, record review, facility staff did not ensure Resident #1 to be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of punitive nature. Which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 18, 2024

Plan of correction: Administrator agrees of the severity of resident’s safety and has agreed to read over Personal Rights regulation and provide all caring staff training the proper training pertaining to Residents Personal Rights. Administrator will provide proof of training and email training documentation do LPA Guerrero on POC due date 1/19/2024.

Type of visit: Office

Licensing Program Analyst (LPA) Bernadette Allen met with Danica Turner Administrator at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office on12/15/2023 at 4:40 PM to initiate a Case Management Office Visit. LPA Allen requested that Danica Turner come into the office to sign an amended complaint investigation control number 56-AS-20230912084226 that was conducted on 10/30/2023. The report was missing some investigation information based on interviews, observations, and medical records. An exit interview was conducted where this report was discussed, and a copy was provided to Danica Turner Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Dec 15, 2023

Allegation investigated: Staff did not provide adequate supervision resulting in resident eloping from facility.

Licensing Program Analyst (LPA) Bernadette Allen an conducted an unannounced visit to initiate and deliver a complaint investigation for the allegation above. LPA Allen met with Danica Turner who was informed of the purpose of the visit. The investigation consisted of observations, interviews with staff members and administrator Danica Turner who stated resident 1 (R1) was in the dining hall and last seen around 2:45 AM. Staff 1 (S1) noticed resident 1 (R1) was not in the dining area. S1 contacted the other two (2) staff members informing them that R1 was missing and requested that a tour of the facility be done inside and outside of the facility to locate R1. While touring the outside area at the main entrance (S1) noticed a free-standing wheelchair where the resident jumped over a fence. S1 canvased the neighborhood and R1 was found at Jack in the Box around 3:20AM where she was being interviewed by the police. S1 identified themselves and the facility that R1 eloped from and was escorted back to the facility. LPA observed unused wheelchairs located in a secure location of the facility inaccessible to residents in care. Substantiated The staff has been directed to do safety checks on R1 hourly and additional training will be conducted to ensure that the residents in care safety needs are met. Based on LPA’s observations and interviews the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is being cited on the attached LIC 9099-D. An exit interview was conducted, and this report was discussed and provided to Danica Turner at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Dec 6, 2023 · control 56-AS-20231128111534

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(4)(A) · Plan of correction due date: Dec 7, 2023

Care of Persons with Dementia (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal.. This requirement is not met as evidenced by: Based on interviews & records review, it was found that R1 does have a history of leaving facilities unauthorized staff members did not ensure the saftey of the residents in care.Staff 1 found R1 30-45 minutes later outside of the facilty at Jack in the Box in the neighborhood. This pose immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 6, 2023

Plan of correction: The Licensee has agreed to provide training on the cited regulation on CCR 87705(4)(A) and submit proof by fax of training with a statement of understanding signed by all staff by the POC date.

Allegation investigated: Staff did not safeguard resident's personal items. Staff did not communicate with authorized representative of resident's broken glasses.

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the mentioned allegations. LPA Allen met with Leilani Cortez Wellness Director who was informed of the purpose of the visit and allegations. LPA Allen conducted interviews with staff members and outside parties who stated not all of resident 1's (R1) personal items were not provided upon discharge. During LPA visit there was one (1) personal item located. The interviews with staff members stated that R1 glasses were taped but they could not confirm or deny if the glasses were broken or if R1's authorized representative was notified. LPA did observe that glasses were broken and outside parites stated that R1's glasses were broken upon arrival. Based on the evidence gathered during the investigation,the above allegation is found to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are being cited on the attached LIC 9099-D. Substantiated An exit interview was conducted where this report was discussed and provided to Leilani Cortez Wellness Director at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Nov 16, 2023 · control 56-AS-20231115085745

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a) · Plan of correction due date: Nov 23, 2023

(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. This requirement is not met as evidenced by: The licensee did not ensure that R1's personal belongings were returned to their responsible party upon their dischage from the facility and 1 item was located during LPA's visit.the state’s words, verbatim · CDSS document, Nov 16, 2023

Plan of correction: The licenssee has agreed to provide training to all staff members regarding the regulation and a signed statement of understanding signed by all staff members by the POC date of 11/23/2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(1) · Plan of correction due date: Nov 23, 2023

A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.....This requirement is not met as evidenced by: The licensee did not report to R1's responsible party or ccl of R1's broken eye glases that are requiredthe state’s words, verbatim · CDSS document, Nov 16, 2023

Plan of correction: The licenssee has agreed to provide training to all staff members regarding the regulation and a statement of understanding signed by all staff members by the POC date of 11/23/2023

Allegation investigated: Staff left resident soiled for an extended period of time. Staff does not provide adequate supervision to residents in care. Staff did not ensure resident's hygiene needs were being met. Staff did not provide resident with clean clothing.

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the mentioned allegations. LPA Allen met with Leilani Cortez Wellness Director who was informed of the purpose of the visit and allegations. LPA Allen conducted interviews with staff members, Resident 1 (R1), outside parties and documents were reviewed. The interviews conducted with staff members stated that residents are check on every two (2) hours or as needed. Staff has also stated R1 could use the restroom as needed but had to be encouraged allowing staff to check their undergarments due to incontinence. Staff also stated they have not experienced any resident being soiled for an extended period. Records were reviewed and it appeared that there is adequate staff to meet the needs of the residents. Records reviewed also shows residents hygiene needs are met daily or as needed. During the visit LPA observed residents in care clothing to be free of stains, odors and their hygiene needs appeared to be met. Unsubstantiated The interviews with outside parties and R1 stated that their hygiene needs were met, and help was provided when needed. Based on records reviewed, observations and interviews with staff, R1 and outside parties, the above finding is Unsubstantiated. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and provided to Leilani Cortez- Wellness Director at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Nov 16, 2023 · control 56-AS-20231115085745

Allegation investigated: Staff are not ensuring that the facility is free of bed bugs.

Licensing Program Analyst (LPA) Bernadette Allen an conducted an unannounced visit to initiate and deliver a complaint investigation for the allegation above. LPA Allen met with Danica Turner who was informed of the purpose of the visit. The investigation consisted of observations of several beds, interviews with staff, residents, and record review. The interviews with residents have stated their beds are free of bed bugs. The interviews with staff stated there have been ongoing treatments for bedbugs which seemed to be resolved. LPA also observed documentation from the pest control that confirms the licensee has taken measures to resolve any issues with bedbugs. LPA also toured the facilities bedrooms H, E, J and Private Room and each bed appeared to be free bedbugs. Based on observations, interviews, and documentation the above finding is Unsubstantiated. Unsubstantiated A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and provided to Danica Turner at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Nov 6, 2023 · control 56-AS-20231102131314

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to the facility to get a complaint amended that was processed on 04/72023. CONTROL NUMBER 56-AS-20230927090814 During the visit LPA had staff member Danica Turner has signed the amended 9099 and 809 issued in error under the complaint. An exit interview was conducted where this report was discussed and a copy of the report was provided to Danica Turner at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Oct 31, 2023

Allegation investigated: Staff did not prevent an outbreak of scabies. Staff left residents in soiled diaper resulting in a rash. Staff did not seek medical attention for residents

Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to deliver the findings for the complaint investigation. LPA met with Leilani Cortez-LVN and she was informed of the purpose of today’s visit. The investigation consisted of interviews with staff members,residents responsible parties and the residents facility files. Allegation #1 Facility did not take necessary steps to prevent a scabies outbreak: LPA conducted interviews with facility staff, administrator Danica Turner, and responsible parties of residents. The interviews with the staff and responsible parties have stated there are no residents at the facility that has been diagnosed by a physician with having scabies. LPA also observed residents files and there was no record or diagnosis of any residents having scabies. During the investigation the LPA was informed of the procedures if there was an diagnosis/outbreak of scabies. Unsubstantiated Allegation #2 Staff left residents in soiled diaper resulting in a rash and Allegation #3- Staff did not seek medical attention for residents. The interviews with the responsible parties for residents and files reviewed all stated that they were aware of residents having a rash and files also revealed that residents in care were being treated by their physicians. Based on the interviews and records reviewed the above findings are Unsubstantiated. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Leilani Cortez-LVN and a copy of the report was provided at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Oct 30, 2023 · control 56-AS-20230823155415

Allegation investigated: Resident sustained an unexplained bruise while in care.

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the allegations above. LPA Allen met with Leilani Cortez-LVN who was informed of the purpose of the visit. The investigation consisted of interviews with staff members, outside parties, and review of Resident 1 (R1) medical records and facility file. The interviews with staff members stated they did not see R1 fall outside they only observed R1 laying on the ground and could not explain how the bruising/scars happened. There were no witnesses that could confirm if the resident fell resulting in unexplained bruising. LPA observed pictures and reviewed medical records that reflect there were bruises and scares on the face and wrist of R1 that could not be explained. LPA did attempt to interview R1on 9/18/2023, but they were at a doctor's appointment. Based on LPA observations, documentation and interviews the above allegation is found to be Substantiated. Substantiated A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is being cited on the attached LIC 9099-D. An exit interview was conducted where this report was discussed, and a copy was provided to Leilani Cortez-LVN at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Oct 30, 2023 · control 56-AS-20230912084226

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(l)(5) · Plan of correction due date: Nov 3, 2023

87705 Care of Persons with Dementia The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: available on the facility premises to permit residents with dementia to wander freely and safely. Interior and exterior space shall be... This requirement is not met as evidenced by: The staff did not esure the saftey of the resident while in care that resulted in unexplained brusing.the state’s words, verbatim · CDSS document, Oct 30, 2023

Plan of correction: The licensee has agreed to provide training to all staff and provide a written statement of understanding of the cited regulation signed by all staff member by the POC of 11/3/2023.

Allegation investigated: Staff did not meet resident's hygiene needs while in care.

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the allegation above. LPA Allen met with Leilani Cortez-LVN who was informed of the purpose of the visit. On10/30/2023 LPA observed Resident 1's (R1) room to be clean and free of odors. LPA also observed R1's bed linen to be clean, free of stains and orders. LPA observed documentation that reflects there is a schedule in place for R1’s weekly hygiene needs or as needed to be met. The interviews with the staff members stated that the residents have schedule for showers twice a week or as needed daily. LPA attempted to have a conversation with R1, but they were not willing to communicate during the visit however LPA did observe R1’s hygiene need seemed to be met, R1’s hands/nails were free of debris, clean clothing free of stains and odors. Unsubstantiated Based on LPA’s observations, interviews, and documents reviewed the allegation as to staff did not meet the resident’s hygiene needs are Unsubstantiated An exit interview where this report was discussed, and a copy was provided to Leilani Cortez-LVN at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Oct 30, 2023 · control 56-AS-20230912084226

Allegation investigated: Staff interfered with a visitation to a resident while in care Staff did not properly groom a resident while in care Staff did not properly maintain a resident's room Staff did not provide adequate care and supervision to a resident Staff retaliated against a resident while in care Staff unlawfully evicted a resident while in care Staff did not ensure a resident was properly fed while in care Staff did not safeguard a resident's personal belongings

Licensing Program Analyst (LPA) Bernadette Allen an conducted an unannounced visit to initiate and deliver findings for the allegations above. LPA Allen met with Dicina Turner Administrator who was informed of the purpose of the visit. LPA attempted to interview six (6) residents (R1, R2, R3, R4, R5 and R6) who could not confirm of deny that their personal rights had been violated by not being allowed to have a clean room, visitors not being allowed, not being properly groomed,staff not providing adequate supervision, being retaliated against, unlawfully being evicted and not properly feed. LPA interviewed six staff members (S1, S2, S3, S4, S5 and S6) and all staff members stated that they have not witnessed any of the client’s personal rights being violated by not being allowed to have a clean room, visitors not being allowed, not being properly groomed, staff not providing adequate supervision, being retaliated against, unlawfully evicted and not being properly feed. During the visit LPA observed residents having visitors, lunch was being served meatloaf mash potatoes, mixed vegetables juice/water/milk. Unsubstantiated LPA observed rooms in Unit A, Unit B, Unit I, Unit E, and Unit H and all rooms were adequately furnished, clean, and free of obstructions. During the visit LPA observed nine (9) staff members which was adequate staffing at the time of visit. LPA interviewed Danica Turner who stated no resident has been unlawfully evicted therefore she couldn’t provide any documentation that could confirm or deny that a client(s) has been unlawfully evicted from the facility. Based on interviews with the staff, clients, and observations the findings are Unsubstantiated. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and provided to Danica Turner with appeal rights at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 2, 2023 · control 56-AS-20230927090814