Roseleaf Oroville

Allegation investigated: Inadequate staffing over July Fourth holiday weekend.- SUBSTANTIATED Facility does not have an activities director. - SUBSTANTIATED Facility is malodorous. – SUBSTANTIATED Housekeeping services are inadequate. - SUBSTANTIATED

/27/2026 10:30 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to deliver the results of a complaint investigation. LPA met with administrator Grace Hawkins and explained the purpose of the visit. During the course of the investigation LPA toured the facility, conducted interviews and reviewed documents. Continued on LIC9099-C Substantiated Inadequate staffing over July Fourth holiday weekend. - SUBSTANTIATED It was reported that on the weekend of July 4th the facility was down to 1 care giver and 1 med tech for the whole facility. LPA reviewed staffing schedule for the weekend of July 3 - 5 2026. The facility used Clipboard registry to fill in staffing gaps that weekend with the exception of July 5 when the registry did not provide any staffing to the facility. July 3 and July 4 show 1 med tech and 2 care staff for the AM and PM shifts, NOC shift had 1 med tech and 1 care staff both days. July 5 shows 1 med tech and no care staff for the AM shift, PM shift shows 1 med tech and 1 care staff, NOC shift had 1 med tech only on shift. It was determined that the facility did not have enough staffing on July 5, 2026 in particular. This allegation is substantiated. Facility does not have an activities director.- SUBSTANITATED It was reported that the facility does not have an activities director. During staff interviews it was learned that staff provided activities for the residents while the facility did not have an activities director. ED stated the last activities director left employment the first week of June. The facility had recently hired a new activities director and they were scheduled to start that week. It was determined that the facility had been without an activities director for approx. 6 weeks. This allegation is substantiated. Continued on LIC9099-C Facility is malodorous. - SUBSTANTIATED It was reported that facility smells like urine. On 08/062026 LPA toured the facility and observed the facility to be malodorous. This allegation is substantiated. Housekeeping services are inadequate. - SUBSTANTIATED It was reported that the facility does not have a housekeeper. On 07/16/2026 LPA toured the facility and found the common areas and resident rooms to be generally clean. LPA reviewed a NOC cleaning log for common areas which states that all areas are to be cleaned, swept and mopped. LPA reviewed pages from a Housekeeping Binder that outlines which resident rooms are required to be cleaned on each day of the week. During staff interviews it was learned that during the period after the housekeeper left the AM and PM shift completed light cleaning and the NOC shift completed deep cleaning duties. Executive Director stated that the housekeeper left employment on June 17, 2026. The facility implemented a cleaning schedule for each shift for care givers to follow. NOC is the slower shift so everyone is responsible for cleaning a certain area. Especially in residents’ rooms if they are smelly or dirty. Kitchen and maintenance staff are assisting. ED stated the facility had just hired a new housekeeper but they had not yet started. LPA confirmed that a new housekeeper was hired and started on 07/17/2026 and left employment on 08/24/2026. On 08/24/026 LPA was notified that the new housekeeper has left employment with the facility, currently the facility does not have a housekeeper. The current staffing level does not support staff being tasked to clean the facility effectively and also complete their care duties. It was determined that the facility did not have a housekeeper for approx. 5 weeks. As of 08/24/2026 the facility again does not have a house keeper on staff. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to Executive Director Grace Hawkins. Resident rooms are not cooled to meet Title 22 temperature requirements.- UNSUBSTANTIATED On 07/16/2026 LPA toured the facility and saw large swamp coolers in three hallways, thermal curtains hung in the lower floor coffee area, large, vented air conditioning units in the lower and upper floor common areas, and individual vented air conditioning units in some resident rooms. LPA took temperature readings and found the lower hallway rooms varied between 72 and 76 degrees and the upper hallways rooms ranged between 70 and 76 degrees. Staff interviews revealed that the room temperatures are better than they have been but some rooms are warmer than others. ED stated the facility had installed curtains to all sun exposed windows in the common areas. We have been trying to lower the temperatures in the hallways to eliminate a warm draft going into resident rooms. The facility has installed three more swamp coolers and two rented ac units in the lower and upper common areas. It was determined that the facility has taken prudent steps to ensuring that the facility temperatures are within Title 22 requirements. Room temperatures are measuring within Title 22 requirements. This allegation is unsubstantiated. No deficiencies. An exit interview was conducted, and a copy of the report was provided to administrator Grace Hawkins.the state’s words, verbatim · CDSS document, Aug 27, 2026 · control 59-AS-20260713084241

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Sep 10, 2026

87411(a) Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on document review and interviews it was determined that the facility did not have enough staff on July 5, 2026. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2026

Plan of correction: The licensee agrees to update current call ou and holiday expectations for staff. In addition licensee shall implement this new policy in staff monthy training. Licensee agrees to submit new policy and staff training sign in sheet to LPA as proof of correction.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(f) · Plan of correction due date: Sep 10, 2026

87219(f) Planned Activities (f) In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities. This requirement was not met as evidenced by: Based on document review and interviews it was determined that the facility did not have an activities director for a period of six weeks. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2026

Plan of correction: The licensee agrees to hire a full time activities director who will fulfill that rle only. Licensee has already hired an activities director. Licensee shall submit proof of hire and list of full time activities to LPA as proof of correction.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Sep 10, 2026

87625(b)(3) Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by: Based on observation it was determined that the facility is malodorous. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2026

Plan of correction: The licensee agrees to submit a plan to licensing regarding how they will ensure that the facility is not malodorous. Licensee agrees to submit this plan to LPA as proof of correction.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 10, 2026

87303 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 was not met as evidenced by: Based on interviews, observation, and document review the facility did not have a housekeeper for approx. 5 weeks. As of 08/24/2026 the facility again does not have a house keeper on staff. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2026

Plan of correction: The licensee agrees to hire a permanant housekeeper for the facility. Licensee shall submit proof of hire to LPA as proof of correction.

Type of visit: Case Management - Deficiencies

01/16/2026 10:30 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Grace Hawkins. Today’s visit is regarding an incident that occurred on 07/07/2026 and was reported to licensing on 07/08/2026. It was reported that on 07/07/2026 06:40 PM Resident 1 (R1) was last seen in the facility hallway walking. Overnight, staff believed R1 was in their room because their door was closed after the shift change as is customary during nighttime hours. Staff did not discover that R1 was not in their room until approximately 5:00 AM on 07/08/2026. Staff immediately initiated the facility’s elopement protocol. Law enforcement, responsible party and administrator were notified. At 9:30 AM on 07/08/2026 law enforcement located R1 at Enloe Hospital which is located 24 miles from the facility. Resident sustained no physical injuries as a result of the incident. Facility staff picked up R1 from the hospital and transported them back to the facility at 2:00 PM on 07/08/2026. During the course of the investigation, it was learned that R1 exited the facility via secured exterior door and exited the secured backyard area. It is unknown how R1 managed to exit the facility grounds. It is unknown how R1 ended up at Enloe Hospital. Continued on LIC809-C It was determined that staff did not provide adequate care and supervision to R1 to prevent them from exiting the secured door to the exterior of the facility backyard and exiting backyard at night which adversely affects the health and safety of R1 due to darkness and street traffic in the area. This is a repeat violation and a civil penalty in the amount of $250.00 is being assessed this day. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to the administrator.the state’s words, verbatim · CDSS document, Jul 16, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jul 30, 2026

87411(a) Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on interviews and document review the facility failed to ensure that 1 of 27 residents was not able to elope from the facility at night and was located in a hospital 24 miles away from the facility. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2026

Plan of correction: The licensee agrees to hold training with all staff on the requirement to provide care and supervision at all times to all residents in care to ensure their safety. The licensee shall submit to LPA a staff training attendance roster which is signed by all staff as proof of correction.

Allegation investigated: Resident rooms are not cooled to meet Title 22 temperature requirements.- SUBSTANTIATED

/15/2026 03:00 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a complaint investigation. LPA met with administrator Grace Hawkins and explained the purpose of the visit. During the visit LPA toured the facility and took random resident room temperatures. Continued on LIC9099-C Substantiated Resident rooms are not cooled to meet Title 22 temperature requirements.- SUBSTANTIATED It was reported that the temperatures in residents’ rooms were too hot. At the time of today's visit the outside temperature for Oroville CA was 98 degrees Fahrenheit. LPA sampled 10 random resident room temperatures and they measured between 82 to 86 degrees. As a temporary solution management has placed portable air conditioners in the affected rooms, and swamp coolers in the hallways and common areas. This allegation is substantiated. A deficiency was issued on May 13, 2026, for the same allegation. As a results of the initial deficiency being issued, the facility had extensive repairs completed to the existing air conditioning system. During the inspection by the air conditioning technician one unit was determined to be inoperable / not repairable. These repairs did not remedy the problem based on the allegation being substantiated again one month later. The facility is required to replace the broken air conditioning unit and have the functioning units re-assessed to ensure they are operating properly to ensure safe temperatures particularly during excessive heat weather events that are very common to the geographic location of the facility. In addition, as a long term remedy the facility has obtained bids to replace all air conditioning units in the building. The administrator anticipates this to be completed soon. This is a repeat violation and a civil penalty in the amount of $250.00 is being assessed on this date and is documented on the attached LIC421. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to Executive Director Grace Hawkins.the state’s words, verbatim · CDSS document, Jun 15, 2026 · control 59-AS-20260615082509

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(b)(2) · Plan of correction due date: Jun 29, 2026

87303(b)(2) Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement was not reached as evidenced by: Based on interviews, inspection and observation the facility failed to ensure that temperatures were within Title 22 requirements. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 15, 2026

Plan of correction: The licensee agrees to hire a licensed contractor to replace the broken air conditioning unit and have the functioning units re-assessed to ensure they are operating properly to ensure safe temperatures throughout the facillity. The facility shall rent or purchase additional cooling units to ensure the facility is cooled properly until the repairs have been completed on the existing units. Licensee shall submit repair / replacement invoices to LPA as proof of correction.

Type of visit: Case Management - Incident

06/04/2026 11:15 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Grace Hawkins. Today’s visit is regarding an incident that occurred on 01/19/2026 and was reported to licensing on 01/20/2026. It was reported that on 01/19//2026 Resident 1 (R1) was sent to Oroville Hospital due to acting out of baseline. Resident was more confused than usual, unsteady on their feet and had bruising on their back and stomach. Resident was diagnosed with s/p likely mechanical fall, dementia, deconditioning. R1 returned from hospital on 01/20/2026. During the course of the investigation, it was learned that R1 had an unwitnessed fall on 01/17/2026. EMS was called to assess R1. EMS notified POA and gave them the choice to transport R1 to hospital. Due to R1 not complaining of pain POA refused transport. When R1 fell on 01/19/2026 and was transported to hospital due to acting out of baseline, increased confusion and being unsteady on their feet. The bruising on R1s torso was discovered by staff on 01/17/2026, per the report of that incident. After the initial fall on 01/17/2026 the facility increased checks for R1 to 15-minute checks. R1 has had no further falls or injuries. No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to administrator Grace Hawkins.the state’s words, verbatim · CDSS document, Jun 4, 2026

Allegation investigated: Staff do not meet resident needs. - UNSUBSTANTIATED Resident does not feel safe. - UNSUBSTANTIATED The facility has no administrator. - UNSUBSTANTIATED

/13/2026 12:45 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to deliver the results of a complaint investigation. LPA met with Michaela Zoggas - resident care coordinator and explained the purpose of the visit. During the course of the investigation LPA conducted interviews and reviewed documents. Continued on LIC9099-C Unsubstantiated Staff do not meet resident needs.- UNSUBSTANTIATED It was reported that on 03/25/2026 Resident 1 (R1) arrived at a medical appointment dirty and smelled of urine. LPA reviewed LIC602 Physicians Report dated 08/12/2025 which states that R1 is able to bathe, dress, groom, and toilet themselves. Resident Appraisal (no date) states that R1 requires help with bathing and personal hygiene. Care Plan states R1 is aggressive when approached for care, staff instructed to document when R1 refuses showers or hygiene assistance. R1 is also aggressive when approached for toileting care and refuses briefs though shows signs of incontinence. LPA reviewed observation notes for R1. 03/30/2026 Refused shower three times. 03/31/2026 Refused to use toilet or get out of bed. 04/01/2026 Refused help from staff, cursed at staff when asked to shower. LPA interviewed 6 staff. All staff interviewed stated when they offer to assist R1 with activities of daily living (ADL) R1 refuses and becomes verbally and physically aggressive toward staff. Staff stated that R1 refuses showers and is physically and verbally aggressive when staff offers to assist R1 with showers and tells staff they have taken a “bird bath” and do not want to shower. Executive Director stated R1 won’t let staff take care of them. R1 is verbally and physically aggressive to staff. R1 went out recently to the hospital and had a psych eval. When R1 goes out to hospital, staff does anything they can to clean R1’s room. R1 went to their doctor on 3/25/26 after a hospital stay. ED states staff can’t force R1 to take a shower but do offer R1 showers and R1 blatantly refuses. It was determined that although it is true that R1 arrived at a medical appointment dirty, R1 continually refuses showers and staff assistance with ADLs. Staff cannot force R1 to shower or accept assistance with ADL’s. This allegation is unsubstantiated. Continued on LIC9099-C Resident does not feel safe.- UNSUBSTANTIATED It was reported that R1 marked on a medical assessment form they do not feel safe where they are living. All staff interviewed stated that R1 has never said they feel unsafe living in the facility. Executive Director stated that R1 has never expressed that they feel unsafe living in the facility. This allegation is unsubstantiated. The facility has no administrator. - UNSUBSTANTIATED It was reported that the facility does not have an administrator. LPA reviewed documentation of Grace Hawkins being assigned as the facility administrator on February 23, 2026. LPA has met with the current administrator at the facility on five separate occasions since they assumed their role. All staff interviewed stated that the administrator is at the facility three to four days each week. Executive Director stated they are at the facility at least three days each week. Staff are aware these are the days the administrator is in the building and staff have 24-hour access to the administrator. It was determined that the facility has an administrator. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to Executive Director Grace Hawkins.the state’s words, verbatim · CDSS document, May 13, 2026 · control 59-AS-20260325132327

Allegation investigated: Resident rooms are not cooled to meet Title 22 temperature requirements. - SUBSTANTIATED

/12/2026 10:30 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a complaint investigation. LPA met with aMichaela Zoggas -Resident Care Coordinator and explained the purpose of the visit. During the visit LPA toured the facility and took random resident room temperatures. Continued on LIC9099-C Substantiated Resident rooms are not cooled to meet Title 22 temperature requirements. - SUBSTANTIATED It was reported that the temperatures in residents rooms were 85-90 degrees and residents were being adversely affected as a result. At the time of today's visit the outside temperature for Oroville CA was 74 degrees farenheit. LPA sampled random resident room temperatures and they measured between 70 to 83 degrees. On the day that the complaint was made the outside temperature was 94 degrees farenheit. Interviews confirmed that some resident rooms measured 90 degrees on that day. Staff had reported to management that residents were very uncomfortable as a result. As a temporary solution management has placed portable air conditioners in the affected rooms. Although the portable air conditioners are a good temporary solution, the facility has historically had issues with maintaining cool temperatures in the summer and fall seasons when the outside temperature in Oroville reaches the from the upper 90's and low 100's throughout these seasons for long periods of time. The licensee is required to permanently fix the air conditioning system to maintain Title 22 temperature requirements. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided.the state’s words, verbatim · CDSS document, May 13, 2026 · control 59-AS-20260511151737

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(b)(2) · Plan of correction due date: May 27, 2026

87303(b)(2) Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement was not reached as evidenced by: Based on interviews and observation the facility failed to ensure that temperatures were within Title 22 requirements. This poses an immediate health and saftey rsik to resident in care.the state’s words, verbatim · CDSS document, May 13, 2026

Plan of correction: The licensee agrees to hire a licensed contractor to repair or replace the exising air conditioning units in the building. Licensee shall submit repair invoices to LPA as proof of correction. LPA will follow-up with random visits to ensure the temerature requirements are being met.

Type of visit: Required - 1 Year

03/30/2026 10:40 AM AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Grace Hawkins cert # 7027610740 exp. 02/24/2028 and explained the purpose of the visit. LPA and the administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and facility grounds. Staff and resident files were reviewed. All employees requiring background checks are cleared. Administrator certificate is current. There is a schedule of recreational activities planned for the residents. There is an adequate supply of toiletries for the residents. Medication is locked in the medication rooms. Medications were reviewed. The facility was observed to be at a comfortable temperature. Common areas, kitchen, resident rooms and bathrooms were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bedding, linens, and towels for residents were observed and found to be clean and in good repair. The facility has a second building that contains 3 resident rooms but is not occupied presently. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Smoke detectors are all operational and are inspected annually by fire marshal and monitored by Cintas continually. There are no pools/bodies of water are on premises. Disaster drills are conducted every six months, the facility has been conducting fire drills every 3 months. Continued on LIC809-C LPA observed the following during the inspection: A broken plexiglass window in the medication room (currently not in use) located in the lower portion of the facility next to the common area. This plexiglass needs to be replaced. Discarded wheelchairs, mattresses, beds etc. located in the sunroom in memory care unit. These items need to be removed. Broken/discarded bed located on the porch on the south side of the facility in the garden area. This needs to be removed. Discarded chairs located in the exterior alcove located on the exterior of the upper memory care medication room. These need to be removed. One window screen was on the ground on the exterior east side of the facility in the garden area. This screen needs to be re-installed. Portion of sidewalk located in the rear garden next to the back fence had puddles of water from the drip irrigation system. This system needs to be inspected and repaired to prevent pooling of water. Discarded commode, walker, and wheelchair in the shaded exterior activities area. These items need to be removed. A deficiency is being cited as a result of today’s inspection and is included on the attached LIC809-D. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Grace Hawkins.the state’s words, verbatim · CDSS document, Mar 30, 2026

Allegation investigated: Licensee is not adhering to facility admission agreement.- UNSUBSTANTIATED

/05/2026 12:00 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to deliver the results of a complaint investigation. LPA met with Executive Director Grace Hawkins and explained the purpose of the visit. During the course of the investigation LPA conducted interviews, and reviewed documents. Continued on LIC9099-C Unsubstantiated Licensee is not adhering to facility admission agreement. - UNSUBSTANTIATED It was reported that the licensee is charging an additional two weeks’ rent after a resident is no longer residing in the community, even after a resident’s belongings have been moved from the room. During interviews there was one resident’s family that was identified as possibly not receiving the refund they were due after the resident passed away. LPA reviewed the admission agreement, monthly invoice and two credits that were issued to the resident’s family. There was no evidence that the facility has been charging residents for two additional weeks after they move out or have passed away. This allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to Executive Director Grace Hawkins.the state’s words, verbatim · CDSS document, Mar 12, 2026 · control 59-AS-20251218125151

Type of visit: Case Management - Deficiencies

03/12/2026 01:30 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Grace Hawkins. Today’s visit is regarding an incident that occurred on 02/16/2026. This is a follow-up visit to deliver findings. It was reported that on 02/16/2026 staff witnessed Staff 1 (S1) retrieve a bottle of Febreze from the upper service area, bend down, and spray the product directly onto Resident 1’s (R1) genital area. Two other staff members were present during the incident. All three staff were suspended as a result. R1’s physician, family, and local law enforcement were notified of the incident. Interviews revealed that staff witnessed Staff 1 spray Febreze on Resident 1. Staff 1 has been fired as a result of this incident. It was determined that Staff 1 (S1) handled R1 in a rough manner when they sprayed the resident with Febreze which violates R1’s personal rights. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to Executive Director Grace Hawkins.the state’s words, verbatim · CDSS document, Mar 12, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Mar 26, 2026

87468.1 (a)(3) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature. This requirement is not met as evidenced by: Based on interviews it was determined that Staff 1 (S1) sprayed R1 with Febreze which violates R1’s personal rights. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 12, 2026

Plan of correction: Administrator agrees to submit a plan of correction advising how this type of violation will be avoided in the future. In addition, the administrator shall provide training for all direct care staff concerning treating residents with dignity and respect. Administrator will schedule the training and provide LPA with the content of the training and signed staff attendance sheet as the POC. The proof of correction is to be received by LPA Knight by 03/26/2026.

Allegation investigated: Staff left residents in soiled diapers for an extended period of time. – SUBSTANTIATED

/24/2026 09:30 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to deliver the results of a complaint investigation. LPA met with Executive Director Grace Hawkins and explained the purpose of the visit. During the course of the investigation LPA toured the facility, conducted interviews, and reviewed documents. Continued on LIC9099-C Substantiated Staff left residents in soiled diapers for an extended period of time. – SUBSTANTIATED It was reported that staff leave the residents soiled diapers for hours. LPA reviewed care plans for Resident 1 (R1) and Resident 2 (R2). Both residents are incontinent and require incontinence care as needed using peri care protocol. Staff instructed to monitor urine and stool, monitor pad. Keep skin dry, keep residents clean and comfortable. The care plans include a schedule of required toileting times per day. LPA reviewed Recorded Care Reports for December 2025 and January 2025 for Resident 1 (R1) and Resident 2 (R2). The care reports show that staff did not record toileting care for ether resident during these months. All staff stated that the residents were not left in soiled diapers. It was determined since staff did not record that toileting care had or had not been completed for either resident there is no proof that the care was provided as outlined in the care plan. LPA is substantiating the allegation based on staff not being competent enough to keep accurate records on incontinent care. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to Executive Director Grace Hawkins. Untrained staff administering medication to residents. – UNSUBSTANTIATED It was reported that a medication technician does not have the required training. LPA reviewed documentation of required medication technician training for Staff 2 with a final exam with a score of 100%. Interviews revealed that staff 2 completed their med tech training which included shadowing an experienced med tech. This allegation is unsubstantiated. Staff worked while under the influence of drugs impairing their ability to provide adequate care and supervision, which presents a risk to residents in care. – UNSUBSTANTIATED It was reported that a staff smokes marijuana and comes back into the facility smelling of marijuana. LPA reviewed the facility’s drug and alcohol abuse policy which states “the use of drugs or alcohol, or being under their influence, jeopardizes the welfare and safety of our residents, employees and visitors, as well as our productivity and efficiency. Your compliance with the following provisions of our workplace drug and alcohol policy is a condition of employment.” All staff interviewed stated they had no knowledge of any staff smoking marijuana while on duty in the facility and working with residents. No staff have witnessed any staff smoking marijuana. All staff stated that no residents had complained of staff smelling of marijuana. This allegation is unsubstantiated. Medication errors - UNSUBSTANTIATED It was reported that a med tech is overmedicating and under medicating a resident. LPA reviewed medication administration record (MAR) for December 2025 and January 2026 for Resident 3 (R3) which revealed that all medications were dispensed as prescribed. All staff interviewed stated they had not witnessed or heard of a med tech over or under medicating any residents. This allegation is unsubstantiated. Staff are not providing adequate food service to residents. – UNSUBSTANTIATED It was reported that the facility does not serve the residents food timely, serve them hard biscuits, and sometimes some residents don’t get any food and must wait for lunch. Staff interviews revealed that if a resident does not want to come to the dining room for meals staff bring a tray to the resident’s room. Residents always get their meals. 1 of 5 staff stated that a hard biscuit was served to the residents one time. This allegation is unsubstantiated. Staff are not responding to residents call buttons. – UNSUBSTANTIATED It was reported that staff don’t respond to the residents’ call buttons because they’re busy sitting around smoking on breaks all day. During a visit to the facility on 01/06/2026 LPA observed staff answering call lights timely. Staff who were interviewed stated they had not seen staff ignoring calls lights. One staff stated they had witnessed other staff sitting on their phones and asked them not to. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to Executive Director Grace Hawkins.the state’s words, verbatim · CDSS document, Feb 24, 2026 · control 59-AS-20260102150659

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 10, 2026

87411(a) Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. This requirement was not met as evidenced by: Based on records review staff did not record toileting care for 2 residents, which poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 24, 2026

Plan of correction: Licensee agrees to provide training to all staff on the requirement to accurately record toileting care of all residents. Licensee shall submit signed staff training sign in sheet as proof of correction. Licensee shall submit POC requirements to LPA by 03/20/2026.

Type of visit: Case Management - Incident

02/24/202602:00 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Grace Hawkins Today’s visit is regarding an incident that occurred on 02/16/2026. It was reported that on 02/16/2026 staff witnessed Staff 1 (S1) retrieve a bottle of Febreze from the upper service area, bend down, and spray the product directly onto Resident 1’s (R1) genital area. Two other staff members were present during the incident. All three staff were suspended as a result. R1’s physician, family, and local law enforcement were notified of the incident. LPA interviewed the Executive Director during the visit. LPA requested documents during the visit to include staff list with telephone numbers, LIC602 physicians report for 1 resident. Further investigation is needed. No deficiencies were issued as a result of the visit. A copy of the report was provided to Executive Director Grace Hawkins.the state’s words, verbatim · CDSS document, Feb 24, 2026

Type of visit: Case Management - Deficiencies

01/29/2026 12:10 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with and Michaela Zoggas Resident Care Coordinator. On 01/20/2026 the department received notification that families had been trying to contact their relatives who live at the facility but no one was answering the phone at the facility. LPA Knight called the facility phone number. No answer and the voice mailbox was full. LPA was unable to leave a message. LPA contacted administrator Bailey Mangone on their mobile phone and informed her of the situation. The administrator later confirmed that the front desk phone could not be heard back in memory care when it rang and the cell reception was not working in memory care. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, and the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to Michaela Zoggas - Resident Care Coordinator.the state’s words, verbatim · CDSS document, Jan 29, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87311 · Plan of correction due date: Feb 12, 2026

87311 Telephones - All facilities shall have telephone service on the premises. This requirement was not met as evidenced by: Based on interviews the licensee failed to ensure that the facility had reliable and correctly functioning telephone service which prevented families from being able to contact residents. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2026

Plan of correction: The licensee agrees to arrange to have a fully functioning telephone that can be heard and answered anytime, anywhere in the facility. The licensee shall conduct staff training on the use of the telephone and the requirement to answer the telephone at all times. Licensee agrees to send LPA staff training sign in sheet as proof of correction.

Allegation investigated: Staff does not prevent resident from physically abusing other residents.

/15/2026 09:30 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Editha McCullough. The purpose of this visit was to conduct a complaint investigation. During the course of the investigation LPA toured the facility and conducted interviews. Continued on LIC9099-C Unsubstantiated Staff does not prevent resident from physically abusing other residents. - UNSUBSTANTIATED It was reported that Resident 1 (R1) physically abuses other residents. During the course of the investigation it was learned that Resident 1 (R1) has a dementia diagnosis and lives in the memory care section of the facility. This behavior is new to R1 within the past 6 months and R1's physician is currently evaluating their medications to determine if a medication change is warranted. This behavior is mostly specific to Resident 2 (R2) who lives in the assisted living section of the facility and the behavior occurs at meal times. There was an incident where R2 sustained a cut to their arm when R1 grabbed them in the dining room. The facility has started keeping the memory care doors closed (unlocked) to help to deter the chance of the two residents interacting. Thus far this intervention has been successful. There have been a couple of other instances of behaviors from R1 toward other clients, there were no reported injuries as a result of these incidents. It was determined that staffing was adequate during the incident when R2 sustained the cut to their arm. This allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to administrator Editha McCullough.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 59-AS-20260106130913

Type of visit: Case Management - Deficiencies

01/16/2026 10:30 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Editha McCullogh. Today’s visit is regarding an incident that occurred on 01/09/2026 and was reported to licensing on 01/12/2026. It was reported that on 01/09/2026 6:53 PM Resident 1 (r1) was found outside by Med Tech who noted that the front door had not been properly closed. R1was discovered sitting in their wheelchair in the parking lot's ditch but was unharmed. Resident Care Coordinator was immediately informed, and resident's POA, was notified. R1 was placed on 30-minute checks and routine checks are being conducted to ensure the front lobby door is latched at all times. During the course of the investigation, it was learned that another resident had been transported back to the facility from hospital and staff were called at 6:52 PM to retrieve this resident. The transportation driver informed staff that they saw a wheelchair outside and staff found R1 sitting in their wheelchair. Staff had last seen R1 inside of the facility at 6:30 PM. Continued on LIC809-C During LPA’s tour of the facility on 01/15/2025 LPA observed that the interior door with key pad entrance was malfunctioning. When staff entered the code the door opened and dis-alarmed. When staff let go of the door LPA observed that the door did not automatically close and latch though the keypad read that the door was secured. This is likely how R1 was able to enter the facility lobby through the unlatched door. Staff did not provide adequate care and supervision to R1 to prevent them from exiting the secured door to the lobby and exiting the exterior lobby door at night which adversely affects the health and safety of R1 due to darkness and street traffic in the area. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to the administrator.the state’s words, verbatim · CDSS document, Jan 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411 · Plan of correction due date: Jan 29, 2026

87411(a) Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on interviews and document review the facility failed to ensure that 1 of 24 residents was not able elope from the facility out into the street at night where they were found in their wheelchair in a parking lot ditch. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: The licensee agrees to hold training with all staff on the requirement to provide care and supervision at all times to all residents in care to ensure their safety. The licensee shall submit to LPA a staff training attendance roster which is signed by all staff as proof of correction.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(a) · Plan of correction due date: Jan 29, 2026

87303 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 was not met as evidenced by: LPA observed that the interior door with key pad entrance was malfunctioning. When staff entered the code the door opened and dis-alarmed. When staff let go of the door LPA observed that the door did not automatically close though the keypad read that the door was secured. This is likely how R1 was able to enter the facility lobby through the unlatched door.This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: The licensee agrees to have the interior lobby door and keypad mechanism inspected and repaired by a licensed professional. Licensee agrees tosumit invoices of inspection and repair to LPA as proof of correction.

Type of visit: Office

On January 8, 2026, at 2:00 pm, an office meeting was held, via Microsoft Teams, as a follow-up to a Non-Compliance Conference (NCC) which was conducted on June 30, 2025 at the licensees additional facility, Roseleaf Gardens (45002775). In attendance representing Community Care Licensing (CCL) were Lauren Crocker, Licensing Program Manager; Troy Ordonez, Licensing Program Manager; Kayla Adkison, Licensing Program Analyst; and Rebecca Knight; Licensing Analyst. Individuals in attendance representing the facility included; Bailey Malagon, Administrator; Mark Cimino, Consultant; Rajesh Rao, Managing Member; Sridhar Nagunuri, Managing Member; and Ramaprasad Samudrala, Managing Member. The purpose of the meeting was to discuss how the facility has responded to issues identified in the previous NCC dated JUne 30, 2025, along with new concerns at both facilities that had been brought to the attention of the Department. Multiple topics were discussed during the meeting, including: • Financial concerns including late annual CCL fees resulting in significant fines, multiple unpaid outside vendors, and unpaid or late utility bills. • Recent maintenance concerns regarding the licensee's additional facility Roseleaf Oroville. • A continuing history of administrator turnover at both Roseleaf Oroville and Roseleaf Gardens (Chico). • Licensee/Administrator reporting requirements, including knowledge of items required to be reported, including utility shut off notices or financial concerns, and the time frames for reporting. Continued on the attached LIC 809-C. In addition to addressing the concerns identified in the Non-Compliance Plan developed on June 30, 2025, it was requested the facility submit further information to the department, to include: - information regarding the newly appointed Interim Administrator at Roseleaf Oroville and any hiring updates on a permanent Administrator. - an outline of the roles and responsibilities of each Managing Member as it pertains to each facilities day-to-day operations. - an outline of Administrator duties and what authorities the Administrator is given in regards to day-to-day operations and financial decisions. - expansion on the letter provided to CCL by the administrator/licensees to include identifying the root causes of previously mentioned problem areas and what steps facility administration intends to take to ensure future compliance with Title 22 Regulations. Licensees were further informed of the intent of CCL to submit a referral to the department's audit unit to conduct a review of all four Roseleaf facilities. No deficiencies are being cited as a result of this meeting. Exit interviewed conducted. A copy of this report was provided to Bailey Malagon, Administrator, via email to obtain signature.the state’s words, verbatim · CDSS document, Jan 8, 2026

Allegation investigated: Resident room has roof leak and electrical outlet is sparking. - SUBSTANTIATED

/05/2026 11:40 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to open a complaint investigation. LPA met with administrative assistant Ashynn Kelley and explained the purpose of the visit. Executive Director (ED) Stacey Baxter was unavailable for the visit. During the investigation LPA toured the facility and conducted interviews. Continued on LIC9099-C Substantiated Resident room has roof leak and electrical outlet is sparking. - SUBSTANTIATED LPA inspected Room 2 and found that there was a water leak in the ceiling on the north-west corner. LPA witnessed buckling paint on the interior wall. LPA viewed the exterior wall of the room (which is in a corner of the building) and determined that a leak was present in the corner. The allegation that the ceiling in a resident room has a leak is substantiated. LPA did not witness sparks coming from electrical outlets in the room and could not substantiate this portion of the allegation. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to executive director Stacey Baxter.the state’s words, verbatim · CDSS document, Jan 6, 2026 · control 59-AS-20260102150659

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303 · Plan of correction due date: Jan 20, 2026

87303 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 was not met as evidenced by: LPA inspected Room 2 and found that there was a water leak in the ceiling on the north-west corner. LPA witnessed buckling paint on the interior wall. LPA viewed the exterior wall of the room (which is in a corner of the building and determined that a leak was present in the corner. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 6, 2026

Plan of correction: Licensee agrees to have the ceiling and walls inspected in Room 2 for leaks and will also ensure that all electrical outlets are functioning safely and have not bee affected by the leak.Licensee agrres tom complete all necessary repairs. Licensee shall send invoices from the contractor to LPA as proof of correction.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: POC

01/06/2026 11:!0 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrative assistant Ashlyn Kelley. Executive Director (ED) Stacey Baxter was unavailable for the visit. In December 2025 the Department received notification that the facility fire alarm system has been experiencing ongoing issues which has generated a significant number of false alarms. On 12/04/2025 LPA issued a citation which required the licensee to replace the fire alarm system. During today’s tour of the facility LPA confirmed that the new fire alarm system is in place and operating. No deficiencies were cited. LPA will clear the deficiency. An exit interview was conducted and a copy of the report was provided to ED Stacey Baxter.the state’s words, verbatim · CDSS document, Jan 6, 2026

Allegation investigated: Licensee is not paying their utility bills and vendors. - SUBSTANTIATED

/18/2025 01:07 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a complaint investigation. LPA met with administrator Stacey Baxter and explained the purpose of the visit. LPA interviewed the executive director during the visit. Continued on LIC9099-C Substantiated Licensee is not paying their utility bills and vendors. - SUBSTANTIATED It was reported that the facility has not been paying their utility bills and vendors for some time. LPA reviewed the following documents: Final notice before disconnection from PGE dated 11/17/2025. This bill was paid on 11/17/2025 the same day as the notice was presented to the facility. The facility currently has a pat due amount of $4,481.00 that is due by 12/23/2025. Overdue notices from water and sewer district. Multiple demands for payment from R.B. Spencer dated 10/14/2025 through 12/04/2025. Telecomm Data LLC unpaid bill dating back to November 2024. Thrifty Rooter invoice dates April 2025. Multiple placement agencies have not been paid. LPA has requested additional documents to include: utility bills for the past 6 months, list of vendors with contact information, list of vendors who have not been paid within the past 6 months. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to executive director Stacey Baxter.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 59-AS-20251218125151

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Jan 22, 2026

87213 Finances The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency. Such request shall explain the need for disclosure. The licensing agency reserves the right to reject any financial report and to request additional information or examination including interim financial statements. This requirement has not been met as evidenced by: Based on LPA record review the facility did not pay their PGE bill which resulted in PGE serving a FINAL NOTICE BEFORE DISCONNECTION. The facility currently has a past due amount of $4,481.00 that is due by 12/23/2025. LPA reviewed past due invoices from multiple vendors who have not been paid by the licensee. This poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: Licensee agrees to pay all past due invoices within 24 hours of this citation. If licensee cannot pay within 24 hours, the licensee shall submit a plan to LPA within 24 hours of how they will pay all past due invoices to all vendors within 30 days. Submit plan to LPA as proof of corretcion.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not allow resident to seek medical attention.- UNSUBSTANTIATED Licensee does not ensure staff are receive adequate training. - UNSUBSTANTIATED Facility is not following a resident’s care plan. - UNSUBSTANTIATED

/18/2025 12:15 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to deliver the results of a complaint investigation. LPA met with administrator Stacey Baxter and explained the purpose of the visit. During the course of the investigation LPA toured the facility, conducted interviews and reviewed documents. Continued on LIC9099-C Unsubstantiated Page 2 Staff did not allow resident to seek medical attention. - UNSUBSTANTIATED It was reported that a resident who was not feeling well wanted to go to the hospital and staff did not arrange for the resident to go to the hospital. LPA reviewed care plan for Resident 1 (R1) which states that R1 is on hospice. The care plan states the supervisor will contact the hospice RN manager and the responsible party as needed. In case of emergencies not related to hospice care (e.g., severe bleeding or injury), staff are to call 911, notify hospice, and inform the responsible party. The Emergency Protocol states that staff will contact hospice for any issues related to the resident’s hospice care. ED stated Resident 1 (R1) is on hospice and the hospice nurse would be called if R1 was not feeling well. Any time the facility has tried to send R1 out to the hospital they have refused to go. This allegation is unsubstantiated. Licensee does not ensure staff are receive adequate training.- UNSUBSTANTIATED It was reported staff are not properly trained in how to assist a resident with a transfer from a wheelchair to the bed LPA reviewed the “New Hire Training Check-Off Sheet” which documents the initial training topics that all new hires undergo when they start working at the facility. Topics include Mobility & Safe Transfers and Bending and Lifting Techniques. ED stated new staff have 20 hours of video training before they start working with residents and they get an additional 20 hours hands on training and shadowing. This training is documented. This allegation is unsubstantiated. Continued on LIC9099-C Page 3 Facility is not following a resident’s care plan. - UNSUBSTANTIATED It was reported staff do not maintain record of resident’s bowel movements. LPA reviewed care tracking sheets for two residents for the month of October 2025. The tracking sheets document bowel movements on all days of the month for all shifts. Both tracking sheets are filled out correctly for both residents. ED stated this is part of each resident’s care plan and staff chart it daily This allegation is unsubstantiated. This agency has investigated the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to administrator Stacey Baxter.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 59-AS-20251020142705

Type of visit: Case Management - Health Checks

12/05/2025 10:45 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Ashlynn Kelley administrative assistant The purpose of the visit was to conduct a heath & safety check of residents in care. On 12/04/2025 LPA issued a deficiency to the facility due to the licensee failing to ensure that common areas and resident rooms were heated to a minimum of 68 F per regulation 87303(b)(1). During today’s visit LPA took temperatures in a total of twelve (12) resident rooms, five (5) of which are located in the lower portion of the facility. LPA also temp checked all common areas. All residents’ rooms and common area temperatures met regulation requirements. No deficiencies were issued as a result of the visit. An exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 5, 2025

Type of visit: Case Management - Deficiencies

12/04/2025 10:20 AM Licensing Program Analyst Rebecca Knight conducted a visit and met with Ashlynn Kelley administrative assistant and Michaela Zogeas Resident Care Coordinator. Executive Director Stacey Baxter was unavailable for the visit. During the vist LPA noticed that the lower portion of the facility was significantly colder than the upper portion. LPA took temperature readings throughout the facility common areas and resident rooms. Temperatures in the lower portion of the facility read from 61 degrees F to 64 degrees F which is much too cold and does not meet regulation requirement. A deficiency is being issued as a result. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, and the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to Executive Director Stacey Baxter.the state’s words, verbatim · CDSS document, Dec 4, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(b) · Plan of correction due date: Dec 5, 2025

87303(b) Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C).This requirement was not met as evidenced by: Based on observation the facility failed to ensure that common areas and resident rooms are at a comfortable temperature which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: Licensee will immediately ensure that common areas and resident rooms in all areas of the facility are heated to a minimum of 68 F. Licensee shall increase the temperature immediately and submit plan to LPA to ensure that the temperature wll be maintained. LPA will follow-up with visits to ensure this requirement has been met.

Type of visit: Case Management - Deficiencies

12/04/2025 09:30 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Ashlynn Kelley administrative assistant and Michaela Zogeas Resident Care Coordinator. Executive Director Stacey Baxter was unavailable for the visit. The Department received notification that the facility fire alarm system has been experiencing ongoing issues which has generated a significant number of false alarms. In 2023 the alarm panel experienced a failure that was temporarily repaired using older parts. The contractor performing the work advised that the panel was near the end of its service life, was experiencing persistent problems, and should be replaced no later than October 6, 2025. On November 13, the contractor emailed the owner, Executive Director, and local fire authority with a formal proposal to replace the system. To date the system has not been replaced. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, and the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to Executive Director Stacey Baxter.the state’s words, verbatim · CDSS document, Dec 4, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Dec 18, 2025

87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on observation and record review the facility failed to ensure that the fire alarm system was in good repair which poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: The licensee agrees to submit a plan to replace the fire alarm system by 12/11/2025. The replacement of the fire alarm system shall be completed by a licensed contractor by 12/18/2025. Licensee will submit signed contract and photograph of the new fire alarm system as proof of correction. LPA will follow-up with a visit to the facility to ensure the plan of correction has been fulfilled. Plan to replace fire alarm system due 12/11/2025. Replacement of fire alarm system due 12/18/2025. ED to contact LPA if contractor needs more time to complete.

Allegation investigated: Staff sent hospice resident to hospital without authorization from POA or Hospice.- UNSUBSTANTIATED Staff didn't follow Hospice Care Plan. - UNSUBSTANTIATED

/06/2025 12:00 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to deliver the results of a complaint investigation. LPA met with Ashlynn Kelley - administrative assistant and explained the purpose of the visit. Executive Director Stacey Baxter gave permission for LPA to deliver findings with Ms. Kelley. During the course of the investigation LPA conducted interviews and reviewed the following documents: LIC602 Physician’s Report, care notes, hospice care plan for one resident, related incident reports, staff list with telephone numbers. Continued on LIC9099-C Unsubstantiated Staff sent hospice resident to hospital without authorization from POA or Hospice. - UNSUBSTANTIATED It was reported that after two falls staff at the facility sent Resident 1 (R1) to the hospital for imaging and told the RP it was the facilities policy to send out the resident. LPA reviewed an incident report dated 09/10/2025 which reports Resident 1 R1) complained of pain in left hip and shoulder following a fall. EMS evaluated R1 and transported to local hospital for further observation. Hospice was present and POA was notified. The facility planned to re-open R1 on hospice upon their return to the facility. Hospice stated on 09/09/2025 R1 had a witnessed fall at 09:00 AM with no injuries and an unwitnessed fall at 04:30 PM during which R1 hit their head and there was a bruise. An hour after the last fall hospice visited R1 and noted resident was oriented and alert stating R1 didn’t seem to have a concussion but had a contusion on the left frontal region of their head. All extremities working fine required assistance ambulating. R1 had a bruise on their left hip. No pain noted. On 09/10/2025 hospice visited R1 to follow-up and things were totally different. Hospice discussed the two falls and spoke with facility staff who stated R1 was not doing well, was in pain and very cognitively different and totally out of baseline. Hospice informed RP who did not want R1 sent out. Facility staff stated they had to send R1 out to be examined at the hospital due to suffering a head strike during the fall. Hospice informed facility staff that they needed to call the RP and inform. Hospice stated they had no choice at that point and the facility sent R1 out to hospital. LPA reviewed the admission summary for Oroville Hospital dated 09/10/2025 which states that the POA for R1 did not wish to have any further studies done. R1 was on comfort care and wanted R1 to return to the facility on comfort care. Facility staff requested R1 undergo hip x-rays to ensure there was no fracture. The hospital completed x-rays of both hips and found no fractures. R1 was returned to the facility on 09/11/2025. Continued on LIC9099-C Executive Director (ED) stated that R1 hit their head and complained of pain to their left hip after the fall. ED explained to the POA that they couldn’t force R1 to go to the hospital but if R1 wasn't evaluated for injuries at the hospital the POA would have to come and get R1 because they were in pain. ED stated If R1 had a brain bleed or broken hip, ED didn’t want the facility to be liable because R1 didn’t get the care they needed. It was determined that Resident 1 (R1) fell twice in one day and struck their head during the second fall. R1 had a change in condition the following day and was out of baseline. Due to R1 suffering a head strike the facility sent R1 out to be evaluated in case they had suffered serious injury. Hospice was present and RP was notified. This allegation is unsubstantiated. Staff didn't follow Hospice Care Plan- UNSUBSTANTIATED It was reported after the resident fell twice they were sent out to the hospital for imaging which was outside of the hospice care plan. LPA reviewed R1’s care plan which includes hospice care plan. The care plan states under pain management that staff are to report any changes in pain levels or the effectiveness of medication to the supervisor immediately. It was determined that Resident 1 (R1) fell twice in one day and struck their head during the second fall. R1 had a change in condition the following day and was out of baseline. Due to R1 suffering a head strike the facility sent R1 out to be evaluated in case they had suffered serious injury which was outside of R1’s hospice care plan. This allegation is unsubstantiated Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to Executive Director Stacey Baxter.the state’s words, verbatim · CDSS document, Nov 6, 2025 · control 59-AS-20250917105940

Allegation investigated: Facility is in disrepair - SUBSTANTIATED

/28/2025 10:40 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a complaint investigation. LPA met with administrator Stacey Baxter and explained the purpose of the visit. LPA interviewed the administrator, and toured the facility during the visit. LPA inspected fifteen (15) resident rooms, food service areas, laundry room, and common areas. Continued on LIC9099-C Substantiated Facility is in disrepair - SUBSTANTIATED LPA inspected the laundry room during the visit and found the condition of the linoleum to be very bad. LPA observed cracked and missing pieces of linoleum which includes the areas around the floor drains which are in bad condition or have been patched. The licensee shall replace the linoleum in the laundry room. LPA also observed two ceiling lighting ballasts that were not in working order, would not light up. Licensee shall replace the light bulbs and /or replace the ballasts as required to bring them to working order. LPA inspected the upper floor food service area and observed that four cabinet drawers were missing and one cabinet door is missing. Licensee shall replace or repair the drawers and doors that are missing or damaged in this area. LPA inspected 15 various resident rooms in the lower and upper areas of the facility. LPA inspected closet / drawers in closets for disrepair and found all that were inspected to be in good repair. LPA did not observe any resident room floors to be warped. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. An exit interview was conducted. A copy of the report was provided to executive director Stacey Baxter.the state’s words, verbatim · CDSS document, Oct 28, 2025 · control 59-AS-20251020142705

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 11, 2025

87303 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 was not met as evidenced by: LPA observed the linolem in the laundry room is damaged / worn, two ceiling lighting ballasts in the laundry room that were not in working order, upper floor food service area observed that four cabinet drawers were missing and one cabinet door is missing.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Licensee agrees to replace the linoleum in the laundry room, replace the light bulbs and / or replace the ballasts in the laundry room, replace or repair the drawers and doors that are missing or damaged in the upper food service area. Licensee shal submit photographs to LPA as proof of repair.

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Medication is being mismanaged. - UNSUBSTANTIATED Facility is not providing adequate food service to residents. - UNSUBSTANTIATED

/28/2025 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to deliver the results of a complaint investigation. LPA met with administrator Stacey Baxter and explained the purpose of the visit. During the course of the investigation LPA conducted interviews and reviewed the following documents: Medication Administration Record (MAR) for August / September 2025, LIC600 Physician’s Report, care notes for two residents, staff list with telephone numbers. Continued on LIC9099-C Unsubstantiated Medication is being mismanaged. - UNSUBSTANTIATED It was reported that staff are not administering a resident's medication and did not fill a resident's prescription. LPA reviewed Resident Observations notes for R1. On 08/28/25 R1 was transported to hospital for evaluation for rash on face and was diagnosed with shingles. 08/29/25 the infection progressed and worsened. On 08/31/2025 R1 complained of pain, PRN Tylenol dispensed. 09/01/25 Tylenol was dispensed and effective. 09/02/25 No complaint of pain or fever. 09/09/25 R1 requested Tramadol for pain, states Tylenol not working, states in extreme pain. 09/05/2025 Med Tech faxed physician for advice. 09/21/2025 through 09/30/25 R1 did not complain of pain. LPA reviewed Medication Administration Record (MAR) for Resident 1 (R1) which shows on 08/29/2025 Erythromycin Ophthalmic Ointment 5 MG/GM, and Valacyclovir anti-viral were added and dispensed the same day. Erythromycin Ophthalmic Ointment was discontinued on 09/05/2025. Valacyclovir was discontinued on 09/06/2025. MAR includes prescription for Tylenol 500 mg with PRN care notes on 09/21/25 and 09/26/2025 “Not effective”. LPA reviewed a written request dated 08/14/2025 from R1’s physician to the pharmacy requesting that Tramadol be discontinued at R1’s request and R1 was “OK with Tylenol”. There are no new orders to start Tramadol for R1 after this discontinuation. LPA reviewed a fax dated 09/05/2025 from med tech to a health clinic requesting advice regarding R1 requesting to speak with their physician about using Tramadol instead of Tylenol as the Tylenol was not helping. On 09/10/2025 Doctor responded that R1 requested to discontinue the Tramadol at their last monthly appointment and stated that Tylenol was fine. Doctor advised if R1 had any concerns they should schedule a telehealth appointment. Staff interviews confirmed that R1 had a prescription for Tramadol but the medication was discontinued. Executive Director stated R1 was prescribed antibiotic eye drops and oral antibiotics for 7 days. R1 had a prescription for Tramadol but it was discontinued by their physician on 08/01/25. R1 refused telehealth appointment with primary care physician to discuss renewing their Tramadol prescription. No new orders for pain medication were received for R1. It was determined that R1’s prescription for Tramadol was discontinued by their physician at R1’s request. R1 refused a telehealth appointment with their physician to renew their Tramadol prescription. No new orders were received for Tramadol or any other pain management medication for R1. This allegation is unsubstantiated. Facility is not providing adequate food service to residents. - UNSUBSTANTIATED It was reported that the food is not healthy and is always cold. LPA reviewed daily photographs of meals that the residents have recently been served and found them to look acceptable. Staff stated that some residents complain about the food in general but they do not say the food is cold. Executive Director stated In February 2025 the facility bought a hot box and have not had any complaints since. Staff serve the lower hall first and then take the hot box to the upper service area and it is plugged in and the meals are served hot. They take the serving dishes in the hot box and staff plate the food for each resident. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to executive director Stacey Baxter.the state’s words, verbatim · CDSS document, Oct 28, 2025 · control 59-AS-20250905121221

Type of visit: Case Management - Deficiencies

10/09/2025 01:00 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced and met with Executive Director (ED) Stacey Baxter. When LPA entered the facility a pronounced mildew odor was observed. LPA toured the facility with the ED. LPA inspected staff restroom that is located in the lobby area and observed an even stronger smell of mildew. LPA inspected the facility kitchen and observed a floor drain that had a very strong mildew odor. LPA reviewed facility sketch and found an electrical room to be located adjacent to the kitchen. LPA inspected the facility electrical room and observed that a large hole had been cut in the center floor of the room. In that hole LPA observed signs that the area had recently been wet and was now being dried by a construction grade fan blowing air into the hole. It seems the licensee is aware that there is an issue and is taking action. However, LPA has issued a physical plant citation this date and requests that the issue be diagnosed and repaired by a licensed contractor who will obtain the required construction permits from the appropriate government authorities. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to Executive Director Stacey Baxter.the state’s words, verbatim · CDSS document, Oct 9, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 23, 2025

(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 was not met as evidenced by: LPA observed a pronounced mildew smell in the facility and observed a large hole had been cut into the floor of the electrical room of the facility which poses a potential health, safety or personal rights risk to persons n care.the state’s words, verbatim · CDSS document, Oct 9, 2025

Plan of correction: Licensee agrees to hire a licensed contractor who will diagnose and repair the issue. The licensed contractor will obtain the required construction permits from the appropriate government authorities. Licensee shall submit a plan that includes anticipated dates of completipn of the repair, name and license number of the contractor, bids for repair, and signed contract as proof of correction. Once the repair has been completed LPA will follow-up with a visit.

Allegation investigated: Staff do not follow reporting requirements. - UNSUBSTANTIATED Staff did not obtain medical care for resident in a timely manner. - UNSUBSTANTIATED Staff do not follow infection control guidelines. - UNSUBSTANTIATED

/14/2025 12:30 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Executive Director Stacey Baxter. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA interviewed the administrator, and 6 staff. The following documents were reviewed: related incident reports. Continued on LIC9099-C Unsubstantiated Page 2 Staff do not follow reporting requirements. - UNSUBSTANTIATED It was reported that the administrator did not report an outbreak of Covid 19 to licensing or public health. On 07/07/2025 LPA received a report from Executive Director reporting 3 residents and 2 staff had tested positive for Covid 19. ED confirmed outbreak had been reported to Butte County Public Health. ED stated that first staff tested positive on 06/23/2025, the first resident tested positive on 07/01/2025, the second staff tested positive on 07/05/2025. According to Butte County Public Health it is not considered an outbreak until three or more people test positive for Covid 19. This threshold was reached on 07/05/2025 and the facility reported to CCLD on 07/07/2025. This allegation is unsubstantiated. Staff did not obtain medical care for resident in a timely manner. - UNSUBSTANTIATED It was reported that a resident had fever, diarrhea, nausea, vomiting, and lethargy symptoms for 3 days before being sent to hospital where they tested positive for Covid 19. LPA reviewed the following incident reports: 06/30/2025 A resident was sent to hospital for diarrhea and vomiting. 07/04/2025 A resident was having a hard time walking, complained of hip pain and was sent to hospital for observation. Both of these residents were diagnosed with Covid 19. During staff interviews it was learned that the first positive resident was sent to the hospital on 06/30/2025 due to diarrhea, vomiting and fatigue. Stated this resident had not been feeling well but initially refused to be sent out. The second positive resident was sent out to hospital because they were not at baseline. This resident was diagnosed and treated for UTI. This allegation is unsubstantiated. Continued on LIC9099-C Page 3 Staff do not follow infection control guidelines.- UNSUBSTANTIATED It was reported that the facility is not following infection control guidelines and residents are not being isolated during a Covid 19 outbreak. LPA reviewed incident report dated 07/07/2025 that states the facility implemented their infection control plan on 07/01/2025 when the first resident tested positive. Report states facility implemented masks in the building, PPE stations, isolation of any resident or employee who has tested positive for 5 days or until symptoms pass, increased sanitization. Staff stated when they found out there was Covid in the building they started to clean more starting the first week of July, but no staff or residents were tested. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to Executive Director Stacey Baxter.the state’s words, verbatim · CDSS document, Aug 14, 2025 · control 59-AS-20250702090756

Allegation investigated: Licensee did not ensure that staff are properly trained.- SUBSTANTIATED

/14/2025 12:00 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Executive Director Stacey Baxter. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA interviewed the administrator, and 6 staff. The following documents were reviewed: MAR for 1 resident, grocery orders for the month of Jun 2025. Continued on LIC9099-C Substantiated Licensee did not ensure that staff are properly trained. - SUBSTANTIATED It was reported that Staff 1 (S1) did not complete training videos and was allowed to administer medications. Executive Director could not provide LPA with documentation to prove that S1 had completed their required medication training. Executive Director stated S1 should have received video training and 20 hours on the floor shadowing and hands on training. ED did not have proof that S1 took their medication training test. It was determined that the facility could not supply proof that S1 had completed their required medication training. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to Executive Director Stacey Baxter. Staff did not administer medication as prescribed.- UNSUBSTANTIATED It was reported that Staff 1 (S1) gave the incorrect dosage of medication to Resident 1 (R1). LPA reviewed Medication Administration Record (MAR) for R1 for the months of June 2025 when the error was reported to have been made. There were no medication errors listed for R1 on this document. 1 of 5 staff that were interviewed stated that S1 had dispensed the wrong medication to R1. This staff could not provide details concerning which (medication name, date) was dispensed incorrectly to R1. 4 other staff who were interviewed stated they had no knowledge that S1 had dispensed medication incorrectly to R1. Executive Director stated they had not heard that R1 had been administered the wrong medication dosage. This allegation is unsubstantiated. Licensee did not store an adequate amount of food for residents in care. – UNSUBSTANTIATED It was reported that that there is not enough food stored at the facility and the residents are not given enough food. LPA reviewed Sysco grocery receipts for the delivery date of 06/03/25 amount $2,410.91, 06/10/25 $1,552.60, 06/17/25 total $1,312.23, 06/24/25 total $1,269.67 Kitchens staff stated that the quantity and quality of the food items that are purchased are good. Kitchen staff stated they follow the menu but occasionally have to substitute some items or ingredients. Care staff stated that the kitchen follows the menu but has to substitute some items because they run out. Executive Director stated they purchase groceries every Thursday from Sysco. They follow the menu and purchase all supplies for three meals a day and also order supplies for snacks and sandwiches. Sysco delivers the weekly order every Tuesday. The monthly food budget is based on the census, and as the census grows the food budget increases. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to Executive Director Stacey Baxter.the state’s words, verbatim · CDSS document, Aug 14, 2025 · control 59-AS-20250701120437

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(6) · Plan of correction due date: Aug 28, 2025

87411 (c)(6) Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. (6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer. This requirement was not met as evidenced by: Based on LPA record review the licensee failed to document that Staff 1 (S1) had completed training before being allowed to dispense medications which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2025

Plan of correction: Licensee agrees to develop a process and plan that outlines how they will ensure that all staff training is documented in staff files. Licensee shall submit this plan to LPA as proof of correction. POC due 08/28/2025.

Allegation investigated: Physical plant violations. - SUBSTANTIATED

/11/2025 12:30 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a complaint investigation. LPA met with Ashlynn Kelley - administrative assistant and explained the purpose of the visit. LPA interviewed the administrative assistant, resident care coordinator and 6 staff during the visit. LPA requested copies of the following documents: MAR for 1 resident, housekeeping schedule, training logs for 1 staff, facility grocery orders for the month of June through July 2025, June and July 2025 menu, staff list with telephone numbers. Continued on LIC9099-C Substantiated Physical plant violations. - SUBSTANTIATED It was reported that licensee does not ensure that kitchen air conditioning is functioning properly. LPA visited the facility at 11:10 AM on 07/11/2025 and took multiple temperature readings in the kitchen. The average temperature reading was 97 degrees F. It was reported that the licensee does not keep the resident rooms clean. LPA inspected three resident rooms. LPA found a large amount of dirt, dust, and debris under resident beds, under night stands and in corners of the rooms. The rooms were generally untidy and unclean. The facility requires more than one house keeping staff in order to ensure that all resident rooms are thoroughly cleaned on a regular basis. Based on observation and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to executive director Stacey Baxter.the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 59-AS-20250701120437

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 25, 2025

87303(a) 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 was not met as evidenced by: LPA obserevd the kitchen temperatre to be 97 degrees F at 11:10 AM. LPA found a large amount of dirt, dust, and debris under resident beds, under night stands and in corners of the rooms. The rooms were generally untidy and unclean. This poses a potential health and safety risk to resident in care and staff working in the facility.the state’s words, verbatim · CDSS document, Jul 11, 2025

Plan of correction: Licensee agrees to install a commercial air conditioning unit in the facility kitchen starting immediately and ending when the hot weather abates for the season. Licensee agrees to hire a second full time house keeping staff for a total of two full time house keeoing staff. The commercial air conditioning unit shall be installed by the end of day 07/11/2025. Licensee shall submit photograph of instaled unit and invocie for its purchase or rental. Licensee shall hire a second full time housekeeper by 07/25/2025 and agrees to submit proof of hire and updated schedule to LPA as proof of correction.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

05/21/2024 10:30 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Stacey Baxter. Today’s visit is regarding an incident that occurred on 05/13/2025. It was reported that on 05/14/2025 Staff 2 (S2) reported to Staff 3 (S3) and Staff 4 (S4) on 05/12/2025 that Staff 1 (S1) was verbally abusive toward Resident 1 (R1) and Resident 2 (R2). S1 was cursing and yelling at the two residents because they were not doing what she wanted them to do. In S2’s statement she stated that S1 had gotten R1 out of bed and wheeled R1 into the hallway, shoved their wheelchair, and told R1 to take themself to the dining room. Executive Director Stacey Baxter reviewed surveillance camera footage and confirmed that S1 shoved R1’s wheelchair into the hallway which caused R1 to roll almost into the wall. At this point another resident came out of their room and pushed R1 to the dining room. S1 came out of the room and walked right past both residents without acknowledging them. An internal investigation was conducted and the employee was terminated as a result. Continued on LIC809-D LPA reviewed the video surveillance of the incident and observed the following: Staff 1 was seen aggressively shoving R1’s wheelchair out of their room and down the hall, R1 nearly hit the wall and was left there alone. Surveillance footage shows S1 come out of the room swinging R1’s soiled brief in the air as they walked down the hall. The surveillance footage shows S1 ignoring R1 as they walked down the hall. It was determined that Staff 1 (S1) handled R1 in a rough manner when they pushed their wheelchair into the hall, left R1 alone and ignored R1 ED terminated S1 as a resuly of this incident. Since ED self reported this incident in detail, shared video footage with LPA and terminated the involved staff a technical violation is being issued as a result of this investigation. No deficiencies were cited as a result.the state’s words, verbatim · CDSS document, May 21, 2025

Type of visit: POC

05/21/2025 09:30 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director (ED) Stacey Baxter. The purpose of the visit was for LPA to conduct an inspection of items that are required as a plan of correction related to a complaint that was completed on 04/17/2025. LPA toured the facility with ED Baxter and RCC Don Daniel. The following deficiencies were cited on the complaint and are required to be completed: Trim back all trees from roof line. LPA inspected and found that tress and shrubs had been pruned and cut back away from the facility. Ensure all screens have been replaced or repaired to ensure proper fit. LPA inspected and found all screens in place and in good condition. Inspect all exterior doors and repair all gaps/openings at bottom of doors to prevent rodents from entering the facility. LPA inspected and found all exterior doors had thresholds and / or weather stripping in place and good condition. All deficiencies related to this complaint have been fulfilled. LPA will issue POC clearance letter. No deficiencies were issued as a result of today’s visit. A copy of the report was provided to administrator Stacey Baxter.the state’s words, verbatim · CDSS document, May 21, 2025

Allegation investigated: Facility is not ensuring that an appropriately skilled professional is assisting the resident with injections. - UNSUBSTANTIATED Facility staff are not dispensing medication as prescribed. - UNSUBSTANTIATED

/28/2025 09:30 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Stacey Baxter. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA interviewed the administrator, resident, and staff. LPA reviewed the following documents Admission Agreement, Physician’s Report, care plan, MAR, glucose monitoring documentation for 1 resident. Continued on LIC9099-C Unsubstantiated Facility is not ensuring that an appropriately skilled professional is assisting the resident with injections. - UNSUBSTANTIATED It was reported that a med tech has been giving Resident 1 (R1) their insulin shots. LPA reviewed the Medication Administration Record (MAR) for R1 which states that R1 takes 20 ml of insulin daily at bedtime. MAR shows that R1 received their insulin shots every evening. Physicians Report states that R1 requires assistance with medication management. During staff interviews it was learned that R1 prepares their own insulin dosage and gives themselves their dosage with staff supervision. Executive Director stated staff assist R1 to dial their insulin pen to the correct dosage and R1 gives themselves their insulin. It was determined that R1 gives themselves their insulin dosage with staff supervision. This allegation is unsubstantiated. Facility staff are not dispensing medication as prescribed. - UNSUBSTANTIATED It was reported that the facility had been giving Resident 1 (R1) insulin without checking their glucose level. LPA reviewed the Medication Administration Record (MAR) for R1 which states R1 checked their glucose levels four times per day using Blood Glucose Test In Vitro Strip. Physicians Report states that R1 requires assistance with medication management. 5 of 5 staff interviewed stated that R1 takes their own glucose readings with “hand over hand’ assistance from staff. Executive Director stated that staff hand R1 their glucose meter and R1 takes their own glucose readings. Staff logs the readings in R1’s MAR. It was determined that R1 has been checking their glucose levels four times per day with assistance from staff. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to administrator Stacey Baxter.the state’s words, verbatim · CDSS document, May 1, 2025 · control 59-AS-20250321155659

Allegation investigated: Facility has an infestation of rodents.- SUBSTANTIATED Facility call system is in disrepair. - SUBSTANTIATED

/16/2025 09:30 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator in training Jessica Owen. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA interviewed the administrator, staff and a pest control technician. LPA requested the following documents: Staff schedules for the month of February 2025, resident assistant job description, and pest control invoices. Continued on LIC9099-C Substantiated Facility has an infestation of rodents. - SUBSTANTIATED On 02/20/2025 LPA observed a small amount of mouse droppings in the closet of Room 12. On 04/13/2025 LPA toured the facility and found mouse droppings in the corner of a resident room that appeared to be dusty and dried up. LPA observed Clark non-toxic rodent monitors located inside of the facility and poison rodent traps located on the exterior of the facility. LPA reviewed service invoices from Clark Pest Control dates 09/11/2023 through 03/17/2025. On these service invoices the technician made the following observations: 7/7/2023 Trees need to be trimmed back from the roof line - Pest and rodent entry into facility. Trim trees at least 4 feet back from structure. Screens Damaged, Missing or Improperly Fit -Pest and rodent entry into facility. Repair, Replace or Install screens. 08/07/2023 Door needs rodent proofing at bottom of door. Gaps/opening at bottom of door will allow pests and rodents into kitchen areas. Recommended action: Install new threshold, adjust door height, or install weather-proofing material. Per pest control invoice dated 03/17/2025 these conditions / observations were still listed on the monthly service invoice. LPA interviewed Clark Pest control who confirmed that these conditions have not been mitigated by the facility. Staff interviews confirmed that staff have observed rodents and/or their droppings in the facility. It was determined that although the facility has monthly pest control services the issue with rodents still persists. There are recommendations that have been made by pest control that the facility has not implemented that may help to alleviate the rodent issue. The allegation is substantiated. Continued on LIC9099-C Facility call system is in disrepair. – SUBSTANTIATED It was reported that call lights outside doors are inoperable to many resident rooms. On 03/05/2025 LPA toured the facility and tested call lights that are located above resident rooms in the hallways in the lower hall. LPA observed that exterior lights above rooms 1,2,3,4,7, and 8 were not functioning, the lights were either very dim or did not light up at all. It was determined that for some rooms the exterior call lights are either dim or not lighting up at all. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Stacey Baxter.the state’s words, verbatim · CDSS document, Apr 17, 2025 · control 59-AS-20250225094703

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 1, 2025

87303(a) 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 was not met as evidenced by: Based on observation, document review and interviews it was determined that although the facility has monthly pest control services the issue with rodents still persists. This poses a potential Health, Safety and Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 17, 2025

Plan of correction: The licensee shall implement and correct all observations made by pest control to help to prevent rodents from entering the facility to include: Trim back all trees 4 feet from roof line, ensure all screens have been replaced or repaired to ensure proper fit, inspect all exterior doors and repair all gaps/opening at bottom of doors to prevent rodents from entering the facility. Licensee shall submit a plan for all repairs with estimated dates of completion to LPA. Licensee shall submit this plan to LPA by 05/01/2025. All repairs must be completed within 30 days. LPA will conduct a follow-up visit to ensure all items have been completed according to the plan as proof of correction.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(1)(i)(c) · Plan of correction due date: May 1, 2025

87303(1)(i)(c) Maintenance and operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more … shall have a signal system which shall: (C) Identify the specific resident living unit. This requirement was not met as evidenced by: Based on observation it was determined that six rooms in the lower hallway have exterior call lights that either do not light or are very dim when the call button is pushed in the resident room. This poses a potential Health, Safety and Personal Rights risk to clients in care.the state’s words, verbatim · CDSS document, Apr 17, 2025

Plan of correction: The licensee shall test all call lights from every resident room in the facility and observe the exterior light of each room. Licensee shall make a list with every room number and the current status of the exterior light (functioning properly, not working, dim). Once the list has been completed licensee shall repair every light that is not lighting correctly and add the date of repair to the list. After all repairs have been completed licensee shall submit final list to LPA as proof of correction. POC due date is 05/01/2025.

Type of visit: Case Management - Incident

02/20/2025 1:20 PM During a visit to the facility Licensing Program Analysts Rebecca Knight and Kayla Adkison were approached by Resident 1 (R1) who reported mice droppings in the closet of their room. LPAs asked R1 if they could inspect their closet. R1 gave LPAs permission and allowed LPAs entry to their room. LPA Knight observed a small amount of mice droppings in the closet. Administrator stated R1 does not ever allow housekeeping into their room to complete deep cleaning. LPAs asked R1 if they would allow housekeeping into their room to clean during the visit. R1 agreed to this. LPAs witnessed housekeeping Staff 1 (S1) at the entry to R1's door. S1 stated that R1 is allowing them in to clean the room that day. LPA Knight will return for a follow-up visit to ensure R1's room has been deep cleaned. Administrator will submit requested documentation of refusals of the times that R1 has refused housekeeping staff entry to clean their room in the past. No deficiencies were issued as a result of today’s visit. A copy of the report was provided to administrator Stacey Baxter.the state’s words, verbatim · CDSS document, Feb 20, 2025

Type of visit: Required - 1 Year

02/20/2025 09:00 AM Licensing Program Analysts (LPAs) Rebecca Knight and Kayla Adkison arrived at the facility unannounced to conduct a Required-1 Year inspection. LPAs met with administrator Stacey Baxter and administrator in training Jessica Owen and explained the purpose of the visit. LPAs and staff toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and facility grounds. Staff and resident files were reviewed. All employees requiring background checks are cleared. Medications were reviewed. There is a schedule of recreational activities planned for the residents. Bedding, linens, and towels for residents were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the residents. Medication is locked in the medication room. The facility was observed to be at a comfortable temperature. Hot water measured between 105 – 120 degrees F. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. The facility has a second building that contains 3 resident rooms but is not occupied presently. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Smoke detectors are all operational and are inspected annually by fire marshall and monitored by Foothill Fire Protection continually. There are no pools/bodies of water are on premises. Disaster drills are conducted every six months, the facility has been conducting fire drills every 3 months. LPAs observed the following deficiencies: During records review LPAs determined that 2 of 6 staff files did not contain First aid certificates. LPAs observed the following during the tour of the facility: Lower activities room common bathroom sink not draining. Room 9 shower floor soiled. Room 26 bathroom light fixture missing glass cover. Room 26 bathroom fan dirty. Discarded items need to be removed from west side entrance to include motorized wheelchair and mattress. Sun room currently has discarded rental equipment (beds, oxygen cannisters, wheelchairs, walkers) that need to be picked up by rental company. Two window screens need to be re-installed on exterior windows on South side of the building. Weeds need to be removed from gutters over entrance to activity room. Discarded metal table needs to be removed from backyard. Discarded heavy metal doors need to be removed from east side activity area. Deficiencies are being cited as a result of today’s inspection and are included on the attached LIC809-D forms. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Stacey Baxter.the state’s words, verbatim · CDSS document, Feb 20, 2025

Allegation investigated: Staff do not ensure that the facility temperature is comfortable. - UNSUBSTANTIATED

/04/2025 09:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator in training Jessica Owen. Administrator Stacey Baxter arrived later. The purpose of this visit was to conduct a complaint investigation. LPA conducted interviews and toured the facility during the visit. During the tour LPA observed the thermostats set at 78 degrees. LPA took random room temperatures in resident rooms in both the lower and upper halls, six total temperatures taken. All temperatures read between 74 to 79 degrees. The allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 4, 2025 · control 59-AS-20250129142610

Type of visit: Case Management - Other

01/08/2024 10:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Stacey Baxter. Today’s visit is regarding incident reports that have been submitted by the facility regarding several falls that recently occurred at the facility specifically involving residents who are on hospice The purpose of the visit was for LPA to have a discussion and provide resources. Administrator stated hospice residents are being re-evaluated for change of condition and suitability for hospice placement. In order to prevent this from occurring the facility will conduct a fall prevention training with all staff. Facility will update fall prevention plan to include staff rounds every 30 minutes (will be documented) and administrator will conduct hourly rounds to ensure that residents are monitored for safety. Administrator will submit a copy of the facility’s updated fall prevention plan to LPA. LPA referred administrator to ​​​​​​​​​Stop Falls Sacramento Coalition for additional resources in fall prevention. https://dhs.saccounty.gov/PUB/StopFallsSacramento/Pages/Stop-Falls-Sacramento-Coalition.aspx No deficiencies were issued as a result of today’s visit. A copy of the report was provided to administrator Stacey Baxter.the state’s words, verbatim · CDSS document, Jan 8, 2025

Type of visit: Case Management - Other

12/17/2024 09:35 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced and met with administrator Stacey Baxter. The purpose of the visit was to conduct an unannounced case management visit to check room temperatures related to a previously substantiated complaint. LPA Knight took temperatures in the lower hall where there are no residents. These rooms registered below Title 22 temperature requirements. The facility has hired a heating /air conditioning company to make required repairs and they are waiting to receive parts to complete the repair of the system. The residents who did live in this area of the facility were moved to the middle and upper halls of the facility in November 2024. LPA will come back and inspect after the repairs have been completed. No residents will live in this portion of the facility until this follow-up inspection has confirmed that temperatures meet Title 22 requirements. LPA Knight took temperatures in ten random rooms in the middle and upper halls of the facility. Those rooms all registered between 72 and 79 degrees which meets Title 22 requirements. No deficiencies were cited during the visit. Exit interview completed. Copy of report was provided to administrator Stacey Baxter.the state’s words, verbatim · CDSS document, Dec 17, 2024

Allegation investigated: Staff do not ensure that the facility temperature is comfortable. - SUBSTANTIATED

/25/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Stacey Baxter. The purpose of this visit was to conduct a complaint investigation. Contimued on LIC9099-C Substantiated Staff do not ensure that the facility temperature is comfortable. - SUBSTANTIATED LPA toured the facility and observed the thermostats set at 71, 73, 74, and 74 degrees in 4 quadrants of the facility. LPA took random room temperatures in resident rooms, ten total temperatures taken. The resident room temperature measured 69 degrees in the upper sections of the facility. In the lower hall resident rooms measured 62 degrees in four resident rooms, this is below the required minimum temperature reading of 68 degrees. The allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Stacey Baxter.the state’s words, verbatim · CDSS document, Nov 25, 2024 · control 59-AS-20241121111343

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b) · Plan of correction due date: Dec 9, 2024

87303(b)(1) Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). Based on LPA observation resident rooms in the lower hall measured 62 degrees in four resident rooms, this is below the required minimum temperature reading of 68 degrees.the state’s words, verbatim · CDSS document, Nov 25, 2024

Plan of correction: Licensee agrees to arrange and complete the repair and/or adjustments of the thermostats and HVAC in the building to ensure that resident rooms reach the required minimum temperature of 68 degrees. Licensee agrees to contact LPA when the adjustments/repars have been completed and LPA will return to the facility to take temperature readings. Due date is December 09, 2024.

Allegation investigated: Facility is not providing adequate supply of laundry detergent to meet resident laundry needs. - SUBSTANTIATED

/14/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Administrator Stacey Baxter. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA conducted staff interviews and reviewed the following documents: admission agreement, care plan, physician’s report, care notes, ADL charting, for 5 residents, receipt for laundry detergent. Continued on LIC9099-C Substantiated Facility is not providing adequate supply of laundry detergent to meet resident laundry needs. - SUBSTANTIATED It was reported that the laundry room was stacked high with laundry and they didn’t have any laundry detergent. LPA reviewed an Instacart delivery receipt dated 08/31/2024 3:28 PM for Tide laundry detergent for a cost of $90.17. 3 of 4 staff stated that they did run out of laundry detergent, the laundry did pile up, but the administrator had detergent delivered. 1 of 4 staff stated that they still had detergent but the new staff did not understand how to use the dispenser. Administrator stated Staff called me and said they were going to run out. I had sent someone to the laundry mat to do the sheets. I had detergent delivered via Insta cart the same day from Costco, they did not run out they said they still had some. It was determined that the facility did run out of laundry detergent and as a result the laundry was piled up in the laundry room. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Stacey Baxter. Staff did not seek timely medical attention for a resident after a fall.- UNSUBSTANTIATED It was reported that a resident fell and the facility refused to send the resident out until two days later. Administrator stated Resident 1 (R1) fell on 8/25/24 R1 was found on the floor, denied being hurt. Hospice was contacted and they said to give whatever R1 needs to be comfortable. Hospice came to the facility that day to evaluate R1. On 8/27/24 R1 was doing well walking around. On 8/30/24 R1 was not bearing good weight, EMS was called and R1 was sent out because that is out of their hospice diagnosis. R1 came back the same day with no new orders. It was determined that R1 fell on 08/25/2024. R1 is on hospice, hospice evaluated R1 at the facility. R1 was sent out due to not being able to bear weight but returned the same day back to the facility with no new diagnosis. This allegation is unsubstantiated. Staff did not meet a resident's incontinence needs. - UNSUBSTANTIATED It was reported that Resident 3 (R3) was in an employee bathroom with dried stool on them and tried to clean themselves up with hospital gloves. No peri care provided. LPA reviewed the care tracking sheets for R1, R3, and R4 for the month of August 2024 and found that all residents had been checked for continence care every 2 hours every day except one day during the hours of 5:00 PM through 9:00 PM for R1 and 7:00 PM through 9:00 PM for R3 and R4 care was not recorded. The ADL was not recorded on the same day of the month for all three residents. During staff interviews it was learned that is not out of the ordinary for Resident 3 (R3), they like to clean themselves independently and staff help R3 when needed. Staff stated that residents are toileted every 2 hours or as needed but some residents refuse which is their right. Administrator stated Residents can go into the bathroom and clean themselves. Residents are toileted according to their care plan. If a resident is really incontinent, we put them on 2 hours checks. This allegation is unsubstantiated. Staff are not providing appropriate wound care to a resident. - UNSUBSTANTIATED It was reported that residents have pressure ulcers and when staff asked for barrier cream they were told they couldn’t have any and they just put a bandage over the wound. Staff interviews revealed that R2 had a stage 1 pressure ulcer on their tailbone and on their heal and are being treated by hospice. Hospice supplied the boot protectors for R2’s heels. Staff rotate R2 every 2 hours. R2 has been prescribed a barrier cream by their physician. Administrator stated On 8/24 Resident 2 (R2) had skin break down, notified by hospice stage 1. Hospice is providing the wound care for R2. If the resident has been prescribed a cream the med tech will apply. The staff are turning R2 and applying the cream. This allegation is unsubstantiated. Staff are not ensuring that residents are swallowing their medications once dispensed. - UNSUBSTANTIATED It was reported that staff do not ensure residents have swallowed their medications. Stated residents have whole pills still in their mouths and on their lips. Staff stated when they dispense medications to residents, they will ask a resident to open their mouth or wait for them to talk to staff to make sure they have swallowed their medications. Administrator stated Staff stay with the residents and monitor and see them swallow their medications. This allegation is unsubstantiated. There are no snacks available for residents during the NOC shift. - UNSUBSTANTIATED It was reported that at night there are no snacks available. There is bread and butter, no fruit or anything for a sandwich, not even juice. Staff stated the cook has been preparing small sandwiches for the NOC shift and leaving snacks out. Staff have access to it all of the times. Administrator stated the kitchen is open and staff have the keypad combination to get in at all times. Staff can go in the kitchen and fix something for the residents, they can fix a sandwich or anything the resident asks for. This allegation is unsubstantiated. There are no clean dishes available during NOC shift. - UNSUBSTANTIATED It was reported that a NOC staff went in kitchen to get silverware and nothing had been cleaned, the dishes were stacked up. Staff stated that the cook cleans the kitchen every night and dishes are available to the NOC shift. Administrator stated All dishes are put away and the kitchen is cleaned spotless before kitchen staff leave at 7:00 pm. If we have stragglers that are slow eaters, staff will place those dishes in the kitchen on a cleaning cart and they are washed in the morning. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to Patricia Goebin-Cuellar.the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 59-AS-20240903094816

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(g)(1) · Plan of correction due date: Nov 28, 2024

87303(g)(1) Maintenance and Operation (g) Facilities which have machines and do their own laundry shall: (1) Have adequate supplies available and equipment maintained in good repair. This requirement was not met as evidenced by: Based on interviews and document review it was determined that the facility ran out of laundry detergent causing the laundry to pile up. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: Licensee agrees to develop a plan that will ensure the facility does not run out of laundry detergent and laundry does not stack up and will submit the plan to LPA as proof of correction. The proof of correction is to be received by LPA Knight by 11/28/2024.

Allegation investigated: Facility is in disrepair. – SUBSTANTIATED Staff do not ensure that facility is clean. - SUBSTANTIATED

/14/2024 01:00 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Stacey Baxter. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA conducted staff interviews and reviewed the following documents: admission agreement, care plan, physician’s report, care notes, ADL charting, for 3 residents, housekeeping schedules, time sheets and assignment sheets, Continued on LIC9099-C Substantiated Facility is in disrepair. – SUBSTANTIATED It was alleged that the facility was in disrepair. LPA visited the facility on 08/26/2024 and observed the following: In the upper dining room LPA observed the section of wall under the breakfast bar had been patched but needed to be painted. LPA observed the section of wall to the left of the hallway (decline) was missing the baseboard and this wall needed to be painted. In this decline hallway the linoleum baseboards needed to be cleaned. LPA observed the baseboard outside of water heater closet was missing and the wall needs to be painted in addition to the hallway wall needs to be painted. Based on LPA observation this allegation is substantiated. Continued on LIC9099-C Staff do not ensure that facility is clean. – SUBSTANTIATED It was alleged that the floors are dirty, the dining area had food on the floors and was very messy, a resident’s room was cluttered, had dirty floors, garbage can was full, bed was not made. During a visit to the facility on 08/26/2024 LPA observed Resident 1's (R1) room was slightly cluttered but was not dirty. LPA observed the shower floor was very dirty. The trash can in the bathroom was not overflowing but did need to be emptied. In the upper dining room LPA observed that the floor had been swept, appeared to be clean yet dark and worn with normal wear and tear. However, LPA did observe significant dirt and grime on the floor next to the double doors. LPA reviewed documents for three residents. The housekeeping weekly assignment sheet states that rooms 8B and 9B are cleaned every Tuesday, and room 17A is cleaned every Wednesday. LPA reviewed housekeeping time sheets which show that there is one full time housekeeping staff. This staff person works 8-hour shift during the day, five days per week. On 08/14/2024 the facility hired a new housekeeper to replace the previous housekeeper. Staff interviews revealed that staff sweep the floor, wipe tables, counters, and chairs after all residents have had their dinner. Resident room floors are mopped twice a week or as needed. Resident trash cans are emptied each shift. Administrator stated We have the deep clean schedule (for each resident room) once a week. Light cleaning is completed by care staff who pick up newspapers, make beds. Staff tries to de-clutter the resident rooms but they have a delicate balance, resident rights, some love clutter. Trash cans are emptied every shift. Resident showers are cleaned weekly according to the house keeping schedule. Based on LPA observation this allegation is substantiated. This allegation will be included in the physical plant citation. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Stacey Baxter. Staff do not respond to resident's call button in a timely manner. - UNSUBSTANTIATED It was alleged that a visitor pulled a resident’s call light, waited 15 minutes and still no staff came to help. LPA toured the facility on 08/26/2024, 09/05/2024, and 11/04/2024 and call bells were answered promptly during the visits. All staff stated that response times are between 2 to 5 minutes but can be up to ten minutes if they are busy attending to another resident. This allegation is unsubstantiated. Staff does not ensure resident is provided clean linen in a timely manner. - UNSUBSTANTIATED It was alleged that staff had removed a resident’s sheets in the morning and never came back. Staff said they are short staffed and didn't have sheets to fit the resident’s bed. Staff interviews revealed that each client has two sets of their own sheets and additionally the facility has a large supply of sheets that can be used. Each resident has their sheets changed twice a week and as needed if soiled. Staff stated that once a resident’s sheets are sent to the laundry a new set is placed on the bed. If a resident’s bed is wet, staff have to let it dry before they can put on the new sheets. Administrator stated New linen is put on with the shower schedule for each resident. Then we have the heavy soakers whose linen is to be changed daily. We always have extra sheets. It’s not just what the resident’s families bring, there is a house supply that they can make the bed from. This allegation is unsubstantiated. Continued on LIC9099-C Staff does not ensure facility is free of odor. - UNSUBSTANTIATED It was alleged that the whole facility had a strong urine odor. LPA toured the facility on 08/26/2024 and 09/05/2024 and did not notice a strong odor. Staff could not recall the facility having a strong smell of urine. Although the complainant experienced a strong smell of urine in the facility on their visit, LPA did not experience this on either day they toured the facility. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to administrator Stacey Baxter.the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 59-AS-20240819142751

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 28, 2024

87303(a) 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 was not met as evidenced by: Based on LPA observation it was determined that the shower floor for 1 resident was very dirty. In the upper dining room LPA observed significant dirt and grime on the floor next to the double doors. In the upper dining room the section of wall under the breakfast bar had been patched but needed to be painted. In the decline to the left of the hallway the section of wall was missing the baseboard and this wall needed to be painted. In this decline hallway the linoleum baseboards needed to be cleaned. The baseboard outside of water heater closet was missing and the wall needs to be painted in addition hallway wall needs to be painted. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: Licensee agrees to submit a plan to LPA that will ensure that resident shower floors are cleaned immediately if they become soiled. Licensee agrees to clean the dirt and grime in the dining room floor next to the double doors. Licensee agrees to paint the breakfast bar wall, decline hallway walls, replace all missing baseboards, clean any dirty baseboards and will submit photographs to LPA as proof of correction. The proof of correction is to be received by LPA Knight by 11/28/2024.

Type of visit: Case Management - Other

11/14/2024 01:00 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced and met with administrator Stacey Baxter. The purpose of the visit was to conduct an unannounced case management visit to deliver / confirm orders to individual for immediate exclusion from all facilities. The staff in question is associated to the facility but administrator confirmed the staff is not employed by the facility currently. LPA Knight served order of immediate exclusion effective 11/14/2024 and explained the "Immediate Exclusion" notice indicating that staff member (S1) cannot be allowed to work, be present, and/or live in a CCL licensed facility, or have contact with clients in any residential facility or child day care licensed by the California Department of Social Services. Therefore, the Department orders the facility to ensure that S1 is not physically present in the facility. Administrator indicated they understood the notice and confirmed that S1 is currently not working at the facility. Exit interview completed. Copy of report was provided to administrator Stacey Baxter. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Nov 14, 2024

Allegation investigated: Staff did not administer resident's medication – SUBSTANTIATED

/18/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Jessica Owen - administrator in training. COO Diania Bingham attended by telephone and gave permission for Ms. Owen to sign the report. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA interviewed the Executive Director, residents and staff. LPA reviewed the following documents: staff list with telephone numbers, Physician’s Report, admission agreement, for 2 residents. MAR, medication orders, medical records for 1 resident. Continued on LIC9099-C Substantiated Staff did not administer resident's medication – SUBSTANTIATED It was reported that a resident was hospitalized due to the facility not giving him his medication (Levothyroxine). LPA document review: MAR dated November and December 2023 do not include the medication Levothyroxine. Physician’s Reported dated 11/07/2023 includes the following information: SECONDARY DIAGNOSIS(ES): a. Treatment/medication (type and dosage)/equipment Hypothyroid, levothyroxine 17Smcg one PO dally. COO stated That med was missed. On the original orders it does have levothyroxine, I don’t see it on the MARS. It was determined that based on interviews and document review due to R1 not receiving his levothyroxine medication, his hyperthyroidism was untreated, and R1 was hospitalized and treated for severe hypothyroidism. This allegation is substantiated. This is a repeat violation, the same violation was cited on 03/19/2024 and 04/23/2024. Civil penalties are being assessed in the amount of $1,000.00 this date on the attached LIC421M for repeat violation within a 12 month period. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to COO Diania Bingham. Staff did not properly care for resident's wounds - UNSUBSTANTIATED It was reported that a resident had cuts on their body that were not being treated. Staff stated that R1 had some skin tears and bruises when he moved in, the med techs would bandage him if he was bleeding but “outside people” were providing wound care. COO stated When he got here from his previous facility, he had existing skin tears that he would pick at and they would reopen that’s what kept him chronic. He had skin tears on his legs and we sent him out to have them look at them and they sent him back to us. The VA was following the wounds on his legs. They kept his skin tears wrapped because he picks at them and doesn’t allow them to heal. The VA does it all, even if it (bandages) comes loose the VA comes in. It was determined that when R1 moved into the facility in January 2024 he had some bruises and skin tears. The VA was providing care for these wounds although the med tech would provide first aid if required. This allegation is unsubstantiated. Staff are not meeting resident's laundry needs - UNSUBSTANTIATED It was reported that a resident had no clean clothes. Staff stated that R1 was showered twice a week and his laundry was done on the same days. Staff always assisted R1 with changing clothes. When R1 moved into the facility he had a lot of shirts, underwear, and jeans but not a lot of pajama bottoms. COO stated that staff have been doing the resident’s laundry. They would encourage him to change his clothes. He was very self-determined and he would self-direct but staff would try to get him to change his clothes. It was determined that when R1 moved into the facility he had a lot of shirts, underwear, and jeans but not a lot of pajama bottoms. Staff were doing R1’s laundry twice a week. This allegation is unsubstantiated. Continued on LIC9099-C Staff are not providing a comfortable temperature for residents - UNSUBSTANTIATED LPA observed the thermostats to all be set at 78 degrees Fahrenheit. Staff interviews revealed that the temperature can vary but overall, the facility is kept at a comfortable temperature. COO stated the thermostat is set at 78 degrees all of them are in controlled environments. It was determined the thermostats are all set for 78 degrees which is a comfortable temperature. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to COO Diania Bingham.the state’s words, verbatim · CDSS document, Jun 18, 2024 · control 59-AS-20240206101159

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 2, 2024

87465(a)(4) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and document review it was determined that due to R1 not receiving his levothyroxine medication, his hyperthyroidism was untreated, and R1 was hospitalized and treated for severe hypothyroidism. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2024

Plan of correction: Licensee agrees to conduct a medication training for all staff exclusive to the requirement of ensuring that residents have all required medications upon admission to the facility and will provide LPA with training subject matter and sign in sheet with dates and staff signatures. Civil penalties are being asessed in the amount of $1,000.00 for repeat violaton within a 12 month period. The proof of correction is to be received by LPA Knight by 07/02/2024.

Allegation investigated: Staff did not meet resident's incontinence needs - UNSUBSTANTIATED

/16/2024 09:45 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrative assistant Jessica Owen. COO Diania Bingham listened to the meeting via telephone call and gave permission for Ms. Owen to sign to receive the complaint findings. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA interviewed the COO and five staff. LPA reviewed the following documents: Admission agreement, Physicians report, care plan, care tracking sheet for 1 resident. Continued on LIC9099-C Unsubstantiated Staff did not meet resident's incontinence needs - UNSUBSTANTIATED It was reported that Resident 1 (R1) uses a condom catheter. On multiple occasions R1’s condom catheter slipped off, staff refused to help R1, and R1 urinated all over themselves. LPA reviewed R1’s LIC602 Physician’s Report which states that R1 is incontinent of bowel and bladder, uses briefs, and is unable to care for their own toileting needs. R1’s Care Tracking Sheet states resident is full assist with all ADLs. Care tracking sheet instructions for toilet: Resident needs help with using the bathroom and transferring to and from wheelchair and toilet. Care Plan instructions: Provide assistance with bathing, dressing, hygiene, provide reminders and assist as needed for incontinence care. The care plan and care tracking sheet do not include the use of a condom catheter. 2 of 5 staff stated that some staff had complained about having to help R1 put the condom catheter back on. 3 of 5 staff stated that R1’s condom catheter slips off. 2 of 5 staff stated that R1 pulls the condom catheter off. COO stated R1 does not have a medical need to use a condom catheter, it is their personal preference. It is a choice of comfort for R1 which is not mandated by R1’s doctor. COO stated that R1’s urologist stated that a condom catheter is not appropriate for R1 to use. No documentation was provided to LPA to fact check this statement. It was determined that staff do provide assistance with R1’s condom catheter although the use of a condom catheter is not included in R1’s care plan. LPA is requesting the facility to update R1’s Care Plan to include the use of a condom catheter and request an exception for R1 to use a condom catheter. This allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED. Exit interview conducted and a copy of the report was provided to COO Diania Bingham.the state’s words, verbatim · CDSS document, May 16, 2024 · control 59-AS-20240308094352

Type of visit: Case Management - Incident

05/09/2024 9:30 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Jessica Owen administrative assistant and explained the purpose of the visit. Today’s visit is regarding an incident that occurred on 04/29/2024 and was reported to licensing on 04/29/2024 by the facility. It was reported that on 4/28/2024 Staff 1 (S1), Staff 2 (S2), Staff 3 (S3) went into Resident 2 (R2)’s room and found Resident 1 (R1) in the room. R1 to become agitated. R1 sat down at the foot of R2’s bed and then hit R2 on their feet. Report states S1 instructed S2 and S3 to restrain and remove R1 from the room. S2 placed their hands under R1’s arms and guided them out of the room. R1 became agitated. S1 stood in front of R2’s door preventing R1 from re-entering the room. R1 started yelling, screaming, and became combative. S1 called 911, Sheriff's Department responded and R1 was transported to Oroville Hospital and placed on a 5150 hold. Administrator in training contacted the psychiatrist on duty at Oroville Hospital. The psychiatrist made some medication changes, determined that a 5150 hold was not required, and released R1 back to the community. R1 was unable to remember any incident or recall the police incident. S1 was terminated as a result of the incident. During the course of the investigation, it was learned that staff guided R1 out of R2’s room in a safe manner. Law enforcement did transport R1 to the hospital and R1 was released back to the facility with updated medications. R1 was not injured as a result of the incident. LPA is requesting that the facility update the resident’s care plan to address the behavior and submit the updated care plan to LPA. The facility has provided care staff with training on de-escalation techniques to keep all residents safe. No deficiencies are being cited as a result of the investigation. Exit interview was conducted and the report was provided to COO Diania Bingham.the state’s words, verbatim · CDSS document, May 9, 2024

Allegation investigated: Staff did not transport resident in a safe manner - SUBSTANTIATED Staff are not bathing a resident in care - SUBSTANTIATED

/02/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Jessica Owen administrative assistant, COO Diania Bingham listened to the delivery of the investigation results by phone and approved Ms, Owen to sign the report. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA interviewed the administrator and 3 staff Admission agreement, care plan, physician's report, ADL charting, Medication Administration Record (MAR), observation notes for March 2024 for 1 resident. Continued on LIC9099-C Substantiated Staff did not transport resident in a safe manner – SUBSTANTIATED It was reported that staff were transporting a wheelchair bound resident in the facility van to a medical appointment. When the van came to a stop, the resident fell out of the wheelchair because the resident did not have a seat belt on. RP stated they received a call from the driver, RP went to help but ultimately the fire department had to come and help get R1 back into their wheelchair. R1 sustained some bruising but no injury as a result. LPA reviewed Resident 1 (R1)’s Physicians Report which states that R1 is non-ambulatory. Care staff had no direct knowledge of the incident. Administrator stated they did hear about the incident. When R1 was interviewed, they said they were strapped in but were unsure how the seatbelt came unlatched. It was determined that staff did not ensure that R1 had a seatbelt on while being transported resulting in R1 falling out of their wheelchair in the facility van. Continued on LIC812-C Staff are not bathing a resident in care - SUBSTANTIATED It was reported that a resident is not being bathed. LPA reviewed R1’s Care plan which states that R1 is to shower on Monday, Wednesday, and Friday of each week. LPA reviewed Physician’s Report for R1 which states that R1 must be supervised while bathing and forgets to bathe. LPA reviewed Care Tracking Sheet for R1 which states the resident is full assist with all activities of daily living (ADLs). The ADL category Showers has instructions: Resident needs assistance with transfers into shower chair, resident also needs assistance with helping bathe. According to the Care Tracking Sheet during the month of March 2024 R1 was scheduled for 12 shower days. Resident had showers on 7 of the 12 scheduled shower days. On 5 of the scheduled shower days R1 was not showered with an outcome on “not completed.” LPA reviewed observation notes for the month of March 2024 for R1 and there were no notations of R1 refusing showers. Staff interviews revealed that R1 complained that the staff would not go in his room to help him. Administrator stated R1 refuses showers, if R1 is refusing, we can’t force him to get in the shower. It was determined that R1 is not being bathed according to their care plan. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to COO Diania Bingham. Resident sustained an unexplained injury while in care - UNSUBSTANTIATED It was reported that a resident has a scrape on their buttocks and it is unknown how the resident got the injury. RP states that R1 a bed sore 3 years ago and it just stayed a dry spot. LPA reviewed R1’s Physicians Report which states that R1 has a history of skin condition breakdown and needs help with care. Staff stated that R1 has a very sore bottom but they would not call it a scrape. Administrator stated they had no knowledge about the scrape on R1’s buttocks. It was determined that R1 does not have a scrape on their buttocks but does a history of a previous pressure injury that has stayed as a dry spot, additionally R1 does have issues with rashes in the area. This is not an injury. This allegation is unsubstantiated. Staff are not giving water to residents in care. - UNSUBSTANTIATED It was reported that the residents are not given water at the facility. On the day of the initial visit LPA observed staff rolling a cart through the facility offering water and lemonade to residents. Administrator stated the facility has a hydration cart and do 2-hour rounds where staff goes in and changes the residents and checks on what they need, gives them water. The facility also offers coffee tea and water time at 10:00 am and 3:00 pm every day. It was determined the facility does offer water and soft drinks to residents. This allegation is unsubstantiated. Continued on LIC9099-C Staff are not properly caring for resident's skin rash - UNSUBSTANTIATED It was reported that a resident is supposed to have the cream placed on a rash after each bath/ shower and the staff are not putting the cream on the resident. LPA reviewed R1’s Physicians Report which states that R! has a history of skin condition breakdown and needs help with care. LPA reviewed R1’s MAR for the month of March 2024 which states that R1 was prescribed Calmoseptine External Ointment 0.44-20.6 % with instructions APPLY TO PERINEAL AREA AS NEEDED FOR REDNES /RASH/ EXCORIATION UNTIL CLEARED. This ointment was applied to R1 on 3/12/2024 and 03/18/2024 with an effective outcome noted. R1’s MAR includes Hydrocortisone External Ointment 2.5 % with instructions to apply to affected area of face/groin twice daily for 2 weeks, then one week off, repeat pattern as needed for flares or irritation. This ointment was applied twice daily from the dates of March 1 through March 22, 2024 with the exception of the following dates: 03/05/24 PM dose, 03/06/2024 through 03/07/2024 AM & PM doses, and 03/08/2024 AM dose were not dispensed. Staff interviews revealed that R1 has lots of creams, ointments, barriers, most of the time R1 will let staff apply the creams. Administrator stated R1 has a rash on their groin, the staff go in the morning to change him, they call the med tech who comes in and puts powder or cream on the rash. It was determined that staff are applying the required creams to R1 as indicated in the Medication Administration Record (MAR). This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED. Exit interview conducted and a copy of the report was provided to COO Diania Bingham.the state’s words, verbatim · CDSS document, May 2, 2024 · control 59-AS-20240314101901

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 16, 2024

87468.2 (a)(4) Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are competent to meet their needs. This requirement was not met as evidenced by: Based on interviews and document review it was determined that staff did not ensure that a seatbelt was placed on R1 prior to transport in the facility van which resulted in R1 falling out of their wheelchair. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 2, 2024

Plan of correction: Licensee agrees to conduct a staff training concerning the requirement to safely transport residents. Licensee shall submit the staff sign in sheet with dates and staff signatures as proof of correction. The proof of correction is to be received by LPA Knight by 05/16/2024.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.2(c) · Plan of correction due date: May 16, 2024

Health and Safety Code section 1569.2(c) provides: (c) "Care and supervision" means the facility assumes responsibility for, or provides… ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement was not met as evidenced by: Based on interviews and document review it was determined that staff did not ensure that Resident 1 is provided assistance in showering with the required number of showers as required in their care plan. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 2, 2024

Plan of correction: Licensee agrees to conduct a staff training concerning the requirement to assist residents with showers. Licensee shall submit the staff sign in sheet with dates and staff signatures as proof of correction. Additionally, licensee agrees to submit a plan for staff to follow specific to providing R1 assistance with showering and ensuring that R1 receives the required number of showers outlined in their care plan. The proof of correction is to be received by LPA Knight by 05/16/2024.

Allegation investigated: Residents are spoken to in an inappropriate manner - SUBSTANTIATED

/23/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with COO Diania Bingham. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA interviewed the administrator, COO, and 3 staff. LPA reviewed the following documents: staff list with telephone numbers, Physician’s Report, admission agreement for 1 resident. Contnued on LIC9099-C Substantiated Residents are spoken to in an inappropriate manner. – SUBSTANTIATED It was reported that staff have heard and seen Staff 4 (S4) yelling at residents. Three staff stated they have witnessed S4 yelling at residents. Staff stated that S4 was subsequently terminated. It was determined that Staff 4 yelled at a resident and was terminated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to COO Diania Bingham. Failure to report per reporting guidelines - UNSUBSTANTIATED It was reported that there was a medication error, where the wrong medication was given to Resident 1 (R1) and Resident 3 (R3) and not all medication errors are being reported to Licensing. LPA previously substantiated the medication error for R3 on 3/19/2024 complaint 59-AS-20240227084128, this incident was reported to licensing. During the investigation concerning the medication error for R1, LPA interviewed R1 who stated staff gave them the wrong medication. R1 stated S1 is the one who caught the mistake after it was given. LPA interviewed S1 who stated that the med tech thought they dispensed the wrong medication to R1 and it was reported to the administrator in training who investigated and determined that the correct medication was dispensed to R1. S1 stated it was not a med error so no incident report was submitted to licensing. It was determined that no medication error occurred for R1 and therefore an incident report was not required to be submitted to licensing. This allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Apr 23, 2024 · control 59-AS-20240308090656

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 7, 2024

87468.1 (a)(1) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff. This requirement was not met as evidenced by: Based on interviews it was determined that S4 yelled at residents. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 23, 2024

Plan of correction: Licensee agrees to conduct training with all staff on the personal rights of residents to be accorded dignity in their relationships with staff and will submit sign in sheet with dates and staff signatures as proof of correction. Staff 4 was terminated from employment as a result of this incident. The proof of correction is to be received by LPA Knight by 05/07/2024.

Allegation investigated: Facility is not dispensing medication as prescribed by physician – SUBSTANTIATED

/23/2024 10:30 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with COO Diania Bingham. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA interviewed the COO and 3 staff. LPA reviewed the following documents: Medication Administration Record, Physicians Report, care plan, admission agreement for 1 resident. Continued on LIC9099-C Substantiated Page 2 Facility is not dispensing medication as prescribed by physician – SUBSTANTIATED LPA reviewed admission agreement that shows that Resident 1 (R1) moved into the facility on 2/13/2024. LPA reviewed Medication Administration Record (MAR) for R1 dated March 3, 2024 through March 30, 2024. The MAR reflects that during this time period R1 missed all doses of the following medications on the following dates: Divaloprex Sodium Oral Tablet Delayed Release 250 mg: Start date 02/13/2024. Not dispensed 03/03/2023 through 03/20/2024. Donepezil HCI Oral Tablet 10 MG Start date 1/27/2024. Not dispensed 03/03/2023 through 03/20/2024. Escitalopram Oral Tablet 5mg: Start date 2/14/2024. Not dispensed 03/04/2023 through 03/20/2024. Furosemide 20 mg: Start date 2/13/2024. Not dispensed 03/02/2023 through 03/20/2024. Melatonin Oral Tablet 3 MG: Start date 3/15/2024. Not dispensed 03/15/2023 through 03/22/2024 2024. Multiple Vitamin oral tablet: Start date 3/5/2024. Not dispensed 3/16/2024 through 03/31/2024. Polythylene Glycol 3350 ORAL Powder: Start date 3/15/2024. Not dispensed 3/16/2024 through 3/31/2024. Continued on LIC9099-C pg 3 Page 3 Quetiapine Fumarate Oral Tablet 25 MG: Start date 2/14/2024. Not dispensed 03/07/2024 through 03/20/2024. Spironolactone Oral Tablet 25 MG: Start date 2/14/2024. Not dispensed 3/02/2024 through 3/20/2024. Vitamin D (Cholecalciferol) Oral capsule 50 MCG: Start date 3/15/2024. Not dispensed 3/16/2024 through 3/28/2024. Ferrous Sulfate Oral Tablet 325 (65 Fe) MG: Start date 03/15/2024. Not dispensed 3/16/2024 through 3/28/2024. All of the aforementioned medications have exception reasons noted in the MAR that say “Not on Hand”, or Waiting on Pharmacy.” Staff interviews revealed that R1 ran out of multiple medications. It was determined that the facility did not ensure that R1 was dispensed their medications as prescribed by their physician due to R1 running out of multiple medications. This allegation is substantiated. Upon inspection of the facility’s compliance history, LPA determined that the licensee was issued a deficiency for the same violation within the past 12 months. As a result, a civil penalty was assessed in the amount of $250.00 on 04/23/2024 on the attached LIC421. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to COO Diania Bingham.the state’s words, verbatim · CDSS document, Apr 23, 2024 · control 59-AS-20240409125620

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 7, 2024

87465(a)(4) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and document review it was determined that R1 ran out of multiple medications for a period ranging from 8 to 18 days. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 23, 2024

Plan of correction: Licensee agrees to conduct a medication training for all med techs concerning the requirement to ensure that residents do not run out of their medications and will provide LPA with training subject matter and sign in sheet with dates and staff signatures. In addition, licensee shall submit a plan to LPA that outlines the process that all med techs must follow to ensure that residents do not run out of medications. The proof of correction is to be received by LPA Knight by 05/07/2024.

Allegation investigated: Staff did not give paramedics the residents emergency paperwork - SUBSTANTIATED

/23/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with COO Diania Bingham. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA interviewed the COO and staff and reviewed the following documents: Admission agreement, Physicians report, hospital discharge papers for 1 resident. Continued on LIC9099-C Substantiated Staff did not give paramedics the residents emergency paperwork - SUBSTANTIATED It was reported that when paramedics were called to transport a resident from the facility to the hospital, the paramedic was told that facility staff did not have identifying information for the resident. This placed the resident in danger due to unknown code status, unknown health history and unknown drug allergies. LPA reviewed Admission agreement for Resident 1 (R1) that shows and admission date to the facility of 01/10/2024. LPA also reviewed paperwork from hospital dated 02/04/2024 which states: Patient presents to the hospital from the assisted care facility and states that his name is R1. However we do not have a reliable birthday, social security number, or other identifying information. He is being admitted as a John Doe at this point. PAST MEDICAL HISTORY unable to obtain. Medical history is also unknown secondary to patient's severe dementia as well as any sort of specific identifying paperwork. Staff interviews confirmed that staff normally have access to the resident’s emergency packet in a file cabinet and on the facility’s computer database. There was no record for R1 in the file cabinet and when staff attempted to access the record on the computer for R1 it was not in the system and they were unable to provide EMS with R1’s record as a result. COO stated that all resident charts are downloaded into the facility’s system. When staff call 911 they click “Emergency Packet” and all documents that need to go to the hospital are right there. The resident’s packet should have been entered into the system within 24 hours of admission but the packet for this resident was not downloaded into the facility’s system. COO stated that the Resident Care Coordinator contacted the social worker at the hospital who confirmed they had all of the information within 1 hour. It was determined that the emergency packet for Resident 1 was not available to be presented to EMS personnel as required. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to COO Diania Bingham. Staff are not trained properly on emergency procedures - UNSUBSTANTIATED It was reported that when paramedics were called to transport a resident from the facility to the hospital, the paramedic was told that facility staff did not have identifying information for the resident. COO stated that staff are trained on the procedure to follow when EMS arrives at the facility to transport a resident. It was determined that staff are trained on emergency procedures. This incident occurred due to staff not having access to R1’s records. This allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Apr 23, 2024 · control 59-AS-20240206083319

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: May 7, 2024

87506(a) 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. This requirement was not met as evidenced by: Based on interviews and document review it was determined that the paper file for R1 was not on file and the facility had not entered the resident’s record into their database where it could be accessed by facility staff. This resulted in staff not being able to provide EMS with the identifying records that are required by EMS in order to transport a resident to hospital. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 23, 2024

Plan of correction: Licensee agrees to submit an updated process that ensures staff access to resident records immediately upon admission of a new resident. Additionally, licensee will conduct staff training on the new process which shall include the requirement to present EMS with resident records any time a resident is transported to hospital. Licensee shall submit staff sign in sheet as proof of correction. The proof of correction is to be received by LPA Knight by 05/07/2024.

Allegation investigated: Staff mismanaged medication resulting in resident to be hospitalized - SUBSTANTIATED

/19/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Stacey Baxter. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA interviewed the COO and 1 med tech. Continued on LIC9099-C Substantiated Staff mismanaged medication resulting in resident to be hospitalized - SUBSTANTIATED LPA reviewed an incident report that was submitted on 02/27/2024 regarding an incident that occurred on 02/22/2024. It was reported that at 8:00 pm a Medication Technician, Staff 1 (S1) reported that they gave another resident's medication to Resident 1 (R1) who was admitted to the facility that same day. EMS was called. EMS arrived, stated that R1’s vital signs were stable and R1 was transported to ER for evaluation. R1 was subsequently hospitalized for observation. No adverse effects were reported as a result of the medication error. R1 returned to community on 02/24/2024. During the course of the investigation, it was learned that when R1 was admitted to the facility their admission record did not include R1’s photograph for identification. S1 failed to follow the facility’s medication safety checks which include confirmation of resident by matching the photograph on file with the resident they are dispensing the medication to. Staff 1 stated that verifying a resident’s photograph (identifying the right person) that a medication is being dispensed is part of the “Six Rights” that the facility uses for dispensing medications. It was determined that even though there was no photograph in the resident’s file, S1 should not have dispensed the medication to R1 without confirming they were dispensing to the correct resident. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Stacey Baxter.the state’s words, verbatim · CDSS document, Mar 19, 2024 · control 59-AS-20240227084128

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 2, 2024

87465(a)(4) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and document review it was determined that a med tech dispensed the wrong medication to 1 resident resulting in hospitalization. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 19, 2024

Plan of correction: Licensee agrees to conduct a medication distribution training for all staff and will provide LPA with training subject matter and sign in sheet with dates and staff signatures. The proof of correction is to be received by LPA Knight by 04/02/2024.

Type of visit: Required - 1 Year

03/19/2024 10:30 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Stacey Baxter and explained the purpose of the visit. COO Diania Bingham was also present for the inspection. LPA Knight and the administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and facility grounds. Staff and resident files were reviewed. All employees requiring background checks are cleared. Medications were reviewed. There is a schedule of recreational activities planned for the residents. Bedding, linens, and towels for residents were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the residents. Medication is locked in a locked cabinet in a locked room. The facility was observed to be at a comfortable temperature. Hot water measured between 105 – 120 degrees F. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. The facility has a second building that contains 3 resident rooms but is not occupied presently. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Smoke detectors are all operational and are inspected annually by fire marshall and monitored by Foothill Fire Protection continually. There are no pools/bodies of water are on premises. Disaster drills are conducted every six months, the facility has been conducting fire drills every 3 months. Continued on LIC809-C LPA reviewed 6 staff files. 4 of 6 staff files had expired first aid training certificates. LPA observed the following during the tour of the facility: East side covered patio: wooden desk, med cart, commode. Back patio next to storage shed: broken patio table. West side of building: twin mattress on patio. Rear of building, south side: 2 window screens laying on the ground. Gutter above south side patio had weeds growing. Refrigerator in kitchen in dining room needs to be defrosted. Medication room: Window screen missing from window. Deficiencies are being cited as a result of today’s inspection and are included on the attached LIC9099-D forms. Exit interview conducted and copy of report was provided to administrator Stacey Baxter.the state’s words, verbatim · CDSS document, Mar 19, 2024

Allegation investigated: Facility is in disrepair - SUBSTANTIATED

/14/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with COO Diania Bingham. The purpose of this visit was to open a complaint investigation. LPA substantiated one allegation and unsubstantiated one allegation during the visit. The remaining two allegations require further investigation and are included on a separate report. LPA interviewed the COO, 1 staff during the visit. Continued on LIC9099-C Substantiated Facility is in disrepair - SUBSTANTIATED LPA toured the facility and made the following observations. It was reported that the facility only has one functioning washer and one of the dryers does not heat up properly. LPA inspected Laundry Room 1 which is located next to the dining room. One dryer was in operation and heating properly. LPA turned on the other dryer and it was functional. One washing machine is inoperable and one is fully functioning. The facility has a second laundry room(Laundry Room 2) that is located at the end of the hallway near the lower hall dining room. This room contains 3 non-functioning washers and 1 large commercial dryer that are all non-functional. This room is currently not being used as a laundry room, it is being used to store housekeeping supplies. The facility plans to start using the second laundry room as the resident census increases. It was reported that the hinge on the laundry room door is preventing the door from closing properly. LPA exited the laundry room to test the door, the door does not close on it's own, the hinge needs to be repaired or replaced. It was reported that the shower hoses in rooms 5, 6, and 9 are leaking. LPA tested the showers in all three resident rooms and all three have very bad leaks. All need to be replaced. Based on interviews, observation and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to COO Diania Bingham.the state’s words, verbatim · CDSS document, Mar 14, 2024 · control 59-AS-20240308090656

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303 · Plan of correction due date: Mar 28, 2024

87303 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 was not met as evidenced by: Based on LPA observation and interviews it was determind that 1 washing machine is inoperational, 3 shower hoses need to be replaced in resident rooms, latch in laundry room door is malfunctioning. This poses a potential health and saftey risk to residents in care.the state’s words, verbatim · CDSS document, Mar 14, 2024

Plan of correction: Licensee agrees to repair washing machine, replace latch on laundry room door, replace malfunctioning hoses in showers in room 5, 6, and 9. Licensee shall submit proof of repairs to LPA by 3/28/2024.

Allegation investigated: Facility failed to provide documents to responsible party. - UNSUBSTANTIATED

/07/2024 12:55 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with COO Diania Bingham. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA interviewed the COO and reviewed the following documents: Identification and Emergency Information, Physician’s Report, Durable Power of Attorney for Health Care, Admission Agreement, Release of Client/Resident Medical Information, Authorization for Disclosure of Health Information for 1 resident, certified mail receipt for package delivery. Continued on LIC9099-C Unsubstantiated Facility failed to provide documents to responsible party - UNSUBSTANTIATED It was reported that the POA has made multiple verbal and one written request for the resident’s file and did not receive the record. LPA reviewed LIC601 Identification and Emergency Information for Resident 1 (R1) which listed R1’s husband as the person responsible for financial affairs, payment for care, Legal Guardian. LPA reviewed Resident 1’s Admission Agreement which lists R1’s daughter as the responsible person. LPA reviewed R1’s Durable Power of Attorney for Health Care which designated R1’s husband and three other family members. LPA also reviewed certified mail reciept for package delivery. COO stated they asked the family member to put the request in writing because the facility needed to include the written records request in the resident’s chart. COO stated they had not received a written request. LPA advised the responsible person (RP) to send an email directly to the COO to request the record and provided the COO’s email address to the RP. COO stated they mailed R1’s record to the address on file, certified mail receipt confirms this statement. LPA was notified by complainant that a large packet including the resident record was received by the responsible party that included intake paperwork, and an assessment. Complainant was expecting to receive any records that contained medical or financial information for the resident. LPA explained to complainant that the facility does not have medical records and advised complainant to contact R1’s medical provider to obtain those records. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED. Exit interview conducted and a copy of the report was provided to COO Diania Bingham.the state’s words, verbatim · CDSS document, Mar 7, 2024 · control 59-AS-20240131143054

Allegation investigated: Facility toilet is in disrepair

/08/2023 10:30 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Michelle Hernandez. The purpose of this visit was to open a complaint investigation. LPA interviewed the administrator and resident care coordinator during the visit. Continued on LIC9099-C Unsubstantiated Facility toilet is in disrepair - UNSUBSTANTIATED It was reported that the toilet in Room 9 was leaking. During the visit LPA inspected the toilet in room 9 and discovered that there was no leak nor water on the floor. Administrator stated that she was informed that the toilet was leaking on 11/05/2023 and it was fixed on 11/06/2023. Resident Care Coordinator stated that he inspected the toilet and fixed the leak. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the finding is UNSUBSTANTIATED. Exit interview conducted and a copy of the report was provided to Executive Director Diania Bingham and administrator Michelle Hernandez.the state’s words, verbatim · CDSS document, Nov 8, 2023 · control 59-AS-20231103141535

Allegation investigated: Staff are not ensuring resident can reach their call button. - SUBSTANTIATED

/01/2023 09:45 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Executive Director Diania Bingham The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA interviewed the Executive Director, administrator and three staff. LPA reviewed the following documents: staff list with telephone numbers, resident list, care tracking sheets, Physicians report, hospice care plans, modified diet order. Continued no LIC9099-C Substantiated Staff are not ensuring resident can reach their call button. - SUBSTANTIATED During a visit to the facility LPA observed that R2's call light was missing the cord. LPA observed a button on the wall without a cord that would normally enable a resident to pull rather than having to be right against the wall to press their call light. 1 of 3 staff stated that some care givers pull Resident 2’s (R2) bed away from the wall so R2 cannot reach their call button. 1 of 3 staff stated If R2 is in their wheelchair they can’t reach their call button. 3 of 3 staff stated that R2’s call light is broken. The string is missing from R2’s call light, there is a red cover that says EMERGENCY on it but R2’s is broken so R2 has to push a tiny knob up or down. R2’s call light just has a button on the wall and R2 has to be in their bed and the bed has to be fully against the wall in order for R2 to reach their call light. It was determined that R2’s call light is missing the cord that would enable R2 to activate their call light even if their bed is not right against the wall. R2 cannot reach their call button unless they are in their bed right against the wall. This allegation is substantiated. Based on interviews, observation and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Michelle Hernandez and Diania Bingham. Page 1 Residents are not showered timely. –- UNSUBSTANTIATED It was reported that residents do not get showers timely. LPA reviewed care tracking sheets for 5 residents for the month of August 2023. 3 of 5 residents received all scheduled showers for the month. 2 of 5 residents showers were not completed twice in 30 days. Residents have the right to refuse showers and any resident who is on hospice may not have showers logged because facility staff are not providing those showers and do not log them. 2 of 3 staff stated residents are showered every two days. 1 staff stated sometimes they run behind but they get the showers done. Administrator stated residents have a shower schedule for twice a week for each resident unless they deny a shower. Chief of Operations stated Residents are showered twice a week depending on the resident’s care plan, staff follow the care plan. A resident can refuse, they have a right to. Staff are doing the showers and they keep approaching a resident if they refuse. It was determined that residents are showered timely unless they refuse. This allegation is unsubstantiated. Continued on LIC9099-C Page 2 Residents miss meals due to staff not transporting them to dining room. - UNSUBSTANTIATED It was reported that residents are not brought down to the dining-room and those residents do not eat. LPA reviewed care tracking sheets for 5 residents for the month of August 2023. Records revealed that residents are served breakfast, lunch and dinner, and 5 of 5 residents ate all of their meals with a few exceptions. There was no pattern of residents not receiving their meals consistently. 3 of 3 staff stated residents are transported to the dining room for meals if they want to go. 3 of 3 staff stated if a resident chooses to stay in their room they are brought their meals. Administrator stated The only ones who are not going are the ones on hospice. We deliver their meal tray to their room. We won’t get them out of bed if they are in a lot of pain. Chief of Operations stated Maybe 6 or 7 residents need to be transported to the dining room for meals. I told staff if a resident doesn’t want to get up at 7am for 8am for breakfast they can make them breakfast later. They have a right to eat when they want to. We bring them a tray if they are not up to going to the dining room. It was determined that residents that need to be transported to the dining room for meals are transported If a resident chooses to not go to the dining room they are being served their meals in their rooms. This allegation is unsubstantiated. Continued on LIC9099-C Page 3 Facility failed to seek timely medical assistance for a resident. – UNSUBSTANTIATED It was reported that Resident 1 (R1) has a wound on the back of their head and RP does not think any wound care is being provided. On 09/06/2023 LPA visited the facility and observed a scab on the back of R1's head. LPA reviewed hospice care plan for R1 which showed R1 was being treated for abscess on 08/23/2023. On 9/26/2023 hospice nursing notes state “Abscess to the back of head resolved with no skin issues noted.” 3 of 3 staff stated that R1 has a wound on their head and is being treated by their hospice nurse for the wound. Administrator stated R1 has a wound on their head, is on antibiotics and the hospice nurse is addressing the wound. Chief of Operations stated it was reported to hospice and the nurse came in, said it was boil and started R1 on antibiotics and provided care. It was determined that R1 has been receiving wound care from their hospice nurse for the abscess on the back of their head. This allegation is unsubstantiated. Continued on LIC9099-C Page 4 Staff did not follow residents special diet order. – UNSUBSTANTIATED It was reported that Resident 3 (R3) is supposed to have a liquid, thickened diet and pureed food and staff are not providing this to R3. LPA reviewed a fax from the facility to the hospice agency reporting that R3 had been choking on food and drinks and needed speech therapy. The hospice agency ordered a pureed diet and thickened liquids as a result on 8/24/2023. R3’s Care tracking sheet revealed that R3 is provided Ensure in between meals. 3 of 3 staff stated Resident 3 is on pureed food and nectar thick liquid. 3 0f 3 staff stated the kitchen is pureeing R3’’s meals. 2 of 3 staff stated that thickener is being added to liquids. Administrator stated R3 is on a liquid, thickened diet and pureed food and the facility is providing the required modified diet for R3. Chief of Operations stated R3’s diet is pureed food with thickened liquids, no consistency. It is posted in the kitchen and dining room, it was well communicated. It was determined that the facility is providing R3 with the special diet as prescribed by the hospice agency. This allegation is unsubstantiated. Continued on LIC9099-C Page 5 Residents are being left in soiled diapers. UNSUBSTANTIATED It was reported that staff is not toileting residents during the PM shift. LPA reviewed care tracking sheets for 5 residents for the month of August 2023. There were no specific abnormalities noted regarding toileting duties not being fulfilled. 3 of 3 staff stated they did not know if residents are being toileted regularly during the PM shift. Administrator stated that residents are being toileted on the PM shift and staff have care plans and charting that they have to do for this task. This allegation is unsubstantiated. Staff smoke marijuana at the facility. - UNSUBSTANTIATED It was reported that staff smoke marijuana on their breaks and then come back and work with the residents. 2 of 3 staff stated they did not know if staff were smoking marijuana at the facility. 1 of 3 staff stated they had heard that staff were smoking marijuana at the facility. Administrator stated It was brought to their attention, they have been watching cameras every day and have not seen anything. Chief of Operations stated There was a rumor that it happened on a PM shift. Someone was bragging about it. We checked the cameras, but we don’t have a camera in the parking lot. I asked all staff if they had seen it and they all said they heard about it but didn’t see it. It was determined that no one witnessed staff smoking marijuana on their breaks and that it was a rumor. This allegation is unsubstantiated. Continued on LIC9099-C Page 6 Staff are taking photographs and video of residents and sharing with one another. - UNSUBSTANTIATED It was reported that staff are taking photographs and video of residents and sharing with one another. 2 of 3 staff stated that there was a staff who had taken photographs of the residents but It was reported to management and then the staff person quit their job. 1 of 3 staff stated they had not heard of staff taking photographs and video of the residents. Chief of Operations stated I received a phone call and was asked if staff could be on Face Time in the facility. The med tech was face timing with their daughter in the community, and said you couldn’t see any residents. The staff person denied that they took a photo of residents. I posted “No phones allowed, protected community, you are not allowed to take video of people in the community.” It was determined that one Med Tech admitted to using Facetime to communicate with their family while inside of the facility. Two staff stated that there was a staff member who had taken photographs of residents, it was reported to management and that staff subsequently quit. There is no evidence that videos or photographs of residents were shared among staff. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. Exit interview conducted and a copy of the report was provided to administrator Michelle Hernandez and Diania Bingham.the state’s words, verbatim · CDSS document, Nov 1, 2023 · control 59-AS-20230830125236

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(A) · Plan of correction due date: Nov 15, 2023

87303(A) Maintenance and Operation - Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more … shall have a signal system which shall: (A) Operate from each resident's living unit. This requirement is not met as evidenced by: Based on LPA interviews and observation it was determined that the call light in 1 resident room is missing the pull cord causing R1 to not be able to activate their call light unless they are in their bed against the wall which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 1, 2023

Plan of correction: Administrator agrees to repair the broken call light in R1’s room and inspect all call lights in the facility to ensure they all have all complete parts and function correctly. Administrator shall submit photograph of repaired call light in R1’s room and submit a facility roster with room numbers, date of inspection, and inspection results to LPA as proof of correction. The proof of correction is to be received by LPA Knight by 11/15/2023.

Allegation investigated: Facility not maintained in good repair

/11/2023 11:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Michelle Hernandez - administrator in tranining. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation LPA interviewed the Executive Director and one staff. LPA reviewed the following documents: staff list with telephone numbers, resident list, electrician’s invoice for replacement of breaker, central air conditioning repair invoices for the past year. Continued no LIC9099-C Unsubstantiated Facility not maintained in good repair It was reported that the temperature inside of R1’s room is uncomfortable and that R1 can't use their portable air conditioning unit provided by the facility to cool down their room because the electrical outlets do not work. When LPA visited the facility on 8/11/2023 the facility was a comfortable temperature. LPA observed four thermostats that were set at temperatures of 76 to 77 degrees farenheit. LPA entered Resident 1's room where the electrical outlets were functioning and there was a portable AC unit that was plugged in and functioning. The room temperature measured 77 degrees farenheit according to LPA's hand-held temperature gauge. LPA reviewed an invoice from Run Electric dated 08/04/2023 that includes details about a repair that was completed for a breaker that was tripping and diagnosed as bad. The breaker was replaced, unit tested and performed satisfactorily per electrician’s notes. LPA also reviewed invoices for multiple visits for the repair and maintenance of the facility’s central air conditioning dating from 06/01/2022 through 05/31/2023. Staff interviews revealed that the breaker in R1’room has been replaced and the facility has been having issues with the central air conditioning and is in the process of fixing it. Administrator stated As soon as I was told the outlet in R1’s room was not working we called the electrician in. He replaced the breaker. Grimes (air conditioning repair company) came in and helped with how to set the thermostats and we set them all at 78 degrees, a comfortable temperature. All of the med techs have the parameters, They all know what is a reportable temperature. We had a problem with one AC and we traced it during temp checks and they were compliant but were running in the 80s. We were trying to figure it out. We got portables for every room that was having issues. We moved the other residents into rooms where the central air conditioning was working properly if their families were willing to move them, the others got portables. It was determined that the facility hired an electrician to complete the repair/replacement of the broken electrical outlets in R1’s room and supplied R1 with a portable air conditioning unit which cools their room sufficiently. In addition, the facility has taken and continues to take reasonable measures to repair the central air conditioning in the facility. Although the allegation may have happened is are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. Exit interview conducted and a copy of the report was provided to Executive Director Diania Bingham.the state’s words, verbatim · CDSS document, Oct 11, 2023 · control 59-AS-20230811085632