Rowntree Gardens

Type of visit: Case Management - Incident

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following on a self-reported incident report received in the Orange County Regional Office (OCRO) on 11/03/23 regarding Resident #1 (R1). LPA met with Administrator (AD) Claudia Lusca-Borcsa and discussed the purpose of the inspection. During the inspection, LPA toured the facility with AD, conducted a health and safety check on R1, observed the facility to be clean and organized, and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food, the electricity and water were running, the facility had soap and paper towels, and the medications and sharps were properly stored. LPA interviewed AD, inspected R1’s medications, and requested and reviewed copies of the resident roster, staff roster, and R1’s resident file. There were no health and safety concerns observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Nov 6, 2023

Type of visit: Office

Office visit to discuss Stipulation and compliance requirements with Randy Brown and Allison Nakatomi. · CDSS reviewed the proposed disclosure language and is working with CFH’s attorney, Pam Kaufmann, on required revisions. · CFH is required to submit the escrow reports quarterly. · CFH is required to include a signed attestation that there were no life care contracts entered for each reporting period. · CFH is required to submit its Financial Plan (Plan) (1793.13(a)(2). CDSS expects to receive the Plan no later than 60 days of the date. · CFH will be required to continue submitted financial statements and occupancy reports. These are required to be submitted quarterly (based on CFH’s fiscal year). CFH’s action taken to comply with Stipulation: · CDSS approves Gary Johnson to serve on CFH’s Board. · CDSS approves the change naming Ann Hablitzel as the Board Chair to separate the roles and ensure and there are no overlapping responsibilities do with the Chief Executive Officer (Randy Brown). · CDSS approves the proposed financial consultant, MHS Consulting (Jeremy Kauffman), to identify implementable strategies to improve the CFH’s performance and provide quarterly reports to CFH and the Department regarding CFH’s financial operations. · CFH has submitted a proposed Continuing Care Contract (Type B/ 36-Month Amortization) to the Department for its review and approval. The Department has reviewed this contract and found that it does not conflict with the Continuing Care Statutes. · CFH has submitted a revised Escrow Agreement to the Department for its review and approval. The Department has reviewed this agreement and found that it complies with the terms in the Stipulation.the state’s words, verbatim · CDSS document, Oct 9, 2023

Allegation investigated: Facility failed to properly assess resident.

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to begin the investigation into the complaint received against this facility on September 27, 2023. LPA Haley was greeted by staff and explained the reason for the visit to Administrator (AD) Claudia Lusca. During the visit LPA Haley interviewed three staff including the Administrator and went to the Memory Care unit to make some observatios. Regarding the allegation: Facility failed to properly assess resident. Details gathered in 3 of 3 interviews contradict the complaint allegation. It was discovered Resident 1 (R1) was assessed by Staff 1 at Kaiser Anaheim August 31, 2023. S1 noted exit seeking behavior and dementia on Rowntree Gardens New Community Member Appraisal form for R1. Due to conversations with R1's family about R1 behaviors, it was determined R1 would be placed on a two-week trial period to see if the resident would acclimate to the facility and eventually become a long term member. Continued on LIC9099C Unfounded R1 was admitted to the facility September 5, 2023 and there was a plan in place to get the resident acclimated to the community and new surroundings. There was a staff member present in the memory care unit to redirect the resident if needed, hourly visual checks were conducted, and eventually 1 on 1 care is required if necessary. On September 5, 2023 facility staff contacted R1's physician because R1 refused to take medication and R1's son was called as well. The residents son came to the facility (9.5.23) because R1 was having a hard time adjusting. September 6, 2023, Rowntree staff contacted R1's physician regarding medication for anxiety and restlessness. Staff also requested recommendations to deal with the residents anxiety and restlessness during the call to the physician. September 7, 2023, Rowntree staff left another message with R1's physician to request assistance because none of the previous calls were returned. On the same day (9.7.23) about 7PM, R1 was able to open an emergency exit in the memory care unit and exit the building. Alarms went off and staff followed right behind the R1 and redirected the resident back to memory care. As a result of this attempted elopement, it was determined R1 would need 1 on 1 care. R1's son was informed of this decision, and Rowntree Gardens covered the cost of the 1 on 1 care for the first day and was willing work with 1 on 1 care providers of the son's choice. September 8, 2023, a care plan meeting was held with R1's son and it was determined the facility would not be able to meet R1's needs. Based on the information gathered during the investigation through interviews and document review, the allegation mentioned above is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 3, 2023 · control 22-AS-20230927122834

Allegation investigated: Jewelry was stolen from resident.

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to deliver the findings on the complaint allegation above. The initial unannounced complaint visit was completed November 10, 2022. The complaint investigation consisted of interviews and document review. During the investigation, LPA Haley interviewed six individuals, attempted one interview, and an effort was made to conduct a follow up interview was unsuccessful. During the investigation it was discovered 4 of 6 witnesses could not confirm the allegation to be true. There was not much knowledge of a theft in the community and there’s no history of items being stolen from residents in the community. Appendix F in the Admission Agreement is the facilities Theft and Loss Policy which describe the actions that will be taken if an item is reported missing. Document review and interview confirm the Theft and Loss Policy was followed by staff. Continued on LIC9099C Unsubstantiated A review of the two combined police reports, do not reveal any break in or burglary to the resident’s room, and no video surveillance was available to be reviewed. Further, document review and interviews reveal, it’s not exactly clear when the items were lost or stolen from the resident. Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegation: Jewelry was stolen from resident, occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is Unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 28, 2023 · control 22-AS-20221101150739

Type of visit: Office

At this office meeting present were: Jerome Haley, Licensing Program Analyst, Marina Stanic, Regional Manager, Icela Estrada, Program Administrator, Paramjit Judge, General Auditor III, Acting Assistant Program Administrator, Allison Nakatomi, CCCB Manager, Katie Anderson, Assistant Branch Chief, Jorge Mojica, General Auditor III, Jacqueline Juarez, Audit Manager, Randy Brown, Chief Executive Officer, Michael Beeman, Chief Financial Officer, Anna Hablitzel, Board Member, Stan Leach, Board Member, Jim Stearman, Attorney, and Pamela Kaufmann, Attorney. The purpose of this meeting was to elaborate on the plans that were discussed at the last meeting held November 14, 2022. The following topics were discussed: · Rescheduling the meeting to a later date · Rowntree Gardens Financial Plan and Viability of their program · Federal Grant Money · Entrance Fees and SNF Profitability · Accuracy of the 2nd monitoring report (Dated 11/10/22) · Selection of a Management Company with decision making authority and Consultant Mr. Randy Brown asked the meeting to be rescheduled due to the financial plan that was intended to be submitted relied on entrance fees. Mr. Brown stated the accusation to rescind the rights of Rowntree Gardens (Rowntree) to engage in continuing care contracts was received the weekend before the meeting and a notice of defense is being filed. It was decided that the meeting would be rescheduled for December 12, 2022 to give Rowntree an opportunity to come up with a financial plan that addresses the financial concerns of the Department. Continued on LIC809 C Assistant Branch Chief Katie Anderson spoke about the financial situation of Rowntree and the viability of their program. Mr. Brown stated that Rowntree’s design was never intended to only be an RCFE and their business model includes entrance fees to finance other portions of their operating expenses. Ms. Anderson brought up the issue that Rowntree was having financial issues before the entrance fees were restricted. Department has been working with the Licensee on plans which they provided; however, Rowntree has not shown sustainable breakeven operations. Mr. Brown explained they tried to address its declining financial position in 2018 and 2019 with the change of its brand name, aligning operating expenses, and marketing; however, due to COVID-19, it was difficult to predict future operations for the last two to three years. Now with normalization, the future is more predictable and the Licensee will put together a plan after consultation with their team and other industry experts. There was further discussion regarding the reasoning why it could benefit the organization to hire a management company with the authority to make changes and how it could cause more financial obligations to the organization. The Actuarial Study from FY2020, especially the list of 12 bullets will be discussed at the next meeting. The next Office Meeting will be held December 12, 2022, at 11:00 AM. An exit interview was conducted, and a copy of this report was provided to the Licensee on December 12, 2022 via email for input, and an email read receipt confirms receipt of the report.the state’s words, verbatim · CDSS document, Nov 28, 2022

Type of visit: Office

At this office meeting present were: Jerome Haley, Licensing Program Analyst, Luz Adams, Licensing Program Manager, Marina Stanic, Regional Manager, Icela Estrada, Acting Assistant Program Administrator, Allison Nakatomi, Staff Services Manager I, Katie Anderson, Assistant Branch Chief, Jorge Mojica, General Auditor III, Jacqueline Juarez, Audit Manager, Randy Brown, Chief Executive Officer, Michael Beeman, Chief Financial Officer, Anna Hablitzel, Board Member, Gary Johnson, Board Member, Jeff Davis, Board Member, Jim Stearman, Attorney, Pamela Kaufmann, Attorney, and Mark Damon, Certified Public Accountant. The purpose of this meeting was to discuss the agreed upon actions noted in the Compliance Plan dated April 25, 2022, to include a review of the licensee’s 2nd Quarter Monitoring Report dated November 10, 2022, which included the following attachments: · Attachment A: Statement of Income and Expenses · Attachment A1: Consumer Census · Attachment B: Balance Sheet 3 Month Summary · Attachment B2: Cash Reserves · Attachment B3: Escrow Funds · Attachment B4: Line of Credit · Attachment B4: Back up LLC Line of Credit The licensee requested to review the 2nd Quarter Monitoring Report to determine accuracy and the Department agreed. Continued on LIC809C Assistant Branch Chief Katie Anderson asked about the licensee's plan for a sale of the additional properties and hiring a management company or consultant with decision-making authority as instructed per Department’s Letter dated May 18, 2021. The licensee advised DSS that based on the Department’s July 23, 2021 letter and a meeting among DSS, Rowntree, its legal counsel and its accounting firm on August 23, 2021, it believed that a management company was not a financially viable option. The licensee added that there is no immediate plan to sell the properties. The licensee was asked about their plan should the Federal Refund be further delayed or not received. The licensee responded that they plan to rely on their line of credit in case the refund is not received. The next Office Meeting will be held November 28, 2022, at 11:00 AM. An exit interview was conducted, and a copy of this report was provided to the Licensee via email within five calendar days of the Office Meeting, and an email read receipt confirms receipt of the report. The Licensee asked for the report to be revised on November 23, 2022. The Department accepted proposed revisions and this final report was provided on December 2, 2022.the state’s words, verbatim · CDSS document, Nov 14, 2022

Allegation investigated: Facility failed to address resident's multiple falls.

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to investigate the above complaint allegation on September 15, 2022. LPA interviewed the Administrator Claudia Lusca, several staff members, Resident 1 (R1), and her Responsible Party (RP). The investigation into the allegation that facility failed to address resident's multiple falls revealed the following: During the initial unannounced visit LPA Haley toured the facility and spoke with facility staff members. LPA Haley received a copy of the Fall Managment policy and during the tour observed several procedures put in place to address and pervent resident's falling. AD Lusca explained some of the procedures in the fall management policy, and explained how the Fallen Stars program works. Furthermore, interviews with staff members revealed what role each staff member plays in the execution of the fall policy. LPA interviewed S1 who explained what happens after a resident falls and and all the steps taken after the fall. For example, residents are given bells Continued on LIC9099C Unfounded and alarms that alert staff. LPA interviewed S2 who explained how staff are always checking on residents in addition to the hourly checks they receive. Staff constantly check on the residents and monitor them while they're in the dining room, and taking walks. Furthermore, S2 showed LPA Haley how the alarms work and explained how the alarms are placed in strategic places in the residents room like the bed, and reclining chair. LPA interviewed S3 who's stationed in the hallway and listens for bells and alarms. S3's job is to respond to the resident if a bell or alarm is heard and make sure the resident is okay. If the resident is found on the floor the next step is to call a nurse to evaluate the resident. S3 is equipped with a 2-way radio to call a nurse if needed and is not allowed to touch the resident at all. Based on the information gathered during the investigation, observation, and review of all documents obtained, the following allegation: Facility failed to address resident's multiple falls, is deemed Unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 14, 2022 · control 22-AS-20220914145127

Type of visit: Office

At this informal conference present were: Jerome Haley, Licensing Program Analyst, Alisa Ortiz, Licensing Program Manager, Marina Stanic, Regional Manager, Icela Estrada, Acting Assistant Program Administrator, Allison Nakatomi, Staff Services Manager I, Katie Anderson, Assistant Branch Chief, Diana Chapman, General Auditor III, Jorge Mojica, General Auditor III, Randy Brown, Chief Executive Officer, Michael Beeman, Chief Financial Officer, Anna Hablitzel, Board Member, Gary Johnson, Board Member, Jeff Davis, Board Member, Jim Stearman, Attorney, and Mark Damon, Certified Public Accountant. The following was discussed: · 1st Quarterly Report dated August 23, 2022 · Improvements Made · Improvements Planed e.g., 6 bed hospice facility, outpatient geriatric frailty syndrome rehabilitation program · List of expected additional funds · Timeframe expected additional funds should be received · Back up plan which ensures resources necessary to meet operating cost. All required financial documentation will be submitted by COB October 21, 2022. The next Informal Conference will be held November 14, 2022 @ 11:00 AM. An exit interview was conducted and a copy of this report was provided to the Licensee via email, and an email read receipt confirms Licensee received the report.the state’s words, verbatim · CDSS document, Oct 10, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management visit at Rowntree Gardens. LPA Haley was greeted upon entering the facility and explained the reason for today's visit. LPA Haley met with Administrator (AD) Claudia Lusca. The purpose of today's visit was to conduct a Case Management visit to discuss an Unusual Incident Report (LIC624) that was sent to the Orange County Adult and Senior Care Program Regional Office September 28, 2022 that involved Staff 1 (S1). During the visit LPA Haley received copies of S1's Medication Training Certificates, Certificate log, and In-Service Training Tracking Log. No deficiencies are being cited during today's Case Management visit. An exit interview was conducted and a copy of this report and LIC 811 was provided.the state’s words, verbatim · CDSS document, Oct 4, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. LPA Haley's temperature was checked and recorded upon entering the facility. Administrator (AD) Claudia Lusca-Borcsa was called and arrived at the reception desk, and was present during the tour of the facility. At 12:11 PM LPA Haley and AD Claudia began the tour of the facility, at that time there were 200 residents present. A screening station was observed at the entrance of the facility equipped with a hands free temperature thermometer, hand sanitizer, and an iPad to fill out the screening questionnaire. The inspection began by checking random resident rooms and recording hot water temperatures. All resident rooms that were inspected were clean, well organized, and had all the necessary requirements: night stand, chair, lamps/lights and storage space. Bathroom water temperatures were recorded in the range of 118.7 - 120 degrees Fahrenheit. LPA Haley advised AD Claudia the importance of monitoring the hot water temperatures and making sure the hot water temperature does not exceed 120 degrees Fahrenheit. LPA Haley observed a supply room well stocked with plenty of PPE. The kitchen was clean and well organized. LPA Haley observed temperature logs on all the refrigerators, and a temperature log book for all the cooked food. The facility has a two day supply of perishable food items and seven day supply of nonperishable food items. All canned food noted to be within expiration date. LPA Haley and AD Claudia inspect random rooms in the memory care unit. All rooms were clean, well organized, and furnished with the necessary items. At 12:45 the alert system in room A21 was tested and was operational. CONTINUED ON LIC 809C DATED 7/6/22. During the inspection LPA Haley observed the required postings on the walls throughout the facility, as well as multiple screening stations throughout the facility. The exterior portion of the facility was clean, and well organized. LPA Haley observed plenty of shaded areas with tables and chairs. Walkways were clean, clear, and free of debris and tripping hazards. No bodies of water were observed. The facility conducts monthly emergency drills. The last fire drill was conducted June 5th, 2022. No deficiencies are being cited during todays visit. An exit interview was conducted and a copy of the report was provided to Administrator Claudia Lusca-Borcsa.the state’s words, verbatim · CDSS document, Jul 6, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management. LPA was greeted, granted entry by staff and explained the reason for the visit. The purpose today's visit was to conduct a Case Management visit to discuss an Unusual Incident Report (LIC 624) that was sent to the Orange County Adult and Senior Care Regional Office July 1, 2022. On today's visit LPA Haley discussed the incident report regarding Resident 1 (R1) with Administrator (AD) Claudia Lusca-Borcsa. LPA Haley received copies of R1's Admission Agreement, Face Sheet, Physicians Report, Individual Service Plan, and Kaiser Discharge Report. No deficiencies are being cited during today's Case Management visit. An exit interview was conducted with Administrator Claudia and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 6, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit for the purpose of conducting a Case Management visit regarding an Unusual Incident Report (LIC 624) received from the facility on 03/09/2022. LPA was greeted at the reception desk by facility staff and explained the reason for the visit today. LPA met with the staff at Skilled Nursing Facility and she contacted via telephone, Assisted Living Administrator Claudia Lusca-Borcsa and informed her I was here. LPA Haley interviewed AD Lusca-Borcsa to follow up on the March 3rd incident regarding Resident 1 (R1). On 03/03/2022, R1 was found in in a sitting position bleeding profusely from the nose. A body assessment was done and noted R1 had an abrasion to the face, left cheek pain, and left eyebrow hematoma. First aid was applied and paramedics transferred R1 to West Anaheim Medical Center for evaluation. LPA Haley was provided copies of R1's: Admission Agreement, Face sheet, Incident Investigation Summary, Physician's Report, and Needs and Service plan. LPA explained if further follow up is required, LPA Haley will return at a later date and time for further information and details regarding this incident. No deficiencies cited at this time. An exit interview was conducted with Administrator Lusca-Borcsa and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 10, 2022

Type of visit: Case Management - Incident

This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Kathrina Chin to follow up on an incident reported to Community Care Licensing. LPA spoke to with Claudia Luska, Executive Director over the telephone and met Celeste Gonzalez, Administrative Assistant and explained the purpose of today’s visit. LPA made a case management visit in order to address five incident reports dated 9/17/2021, 9/28/2021, 10/8/2021, 10/9/2021, and 10/20/2021. The following incidents occurred: It was reported that resident 1 (R1) on 9/17/2021 who resides in the Dementia Unit fell on his way to the bathroom. He sustained a hematoma to his left eye and left forearm skin tear. The facility called 911 emergency personnel and transferred to UCI Medical Center. R1 remains in Rowntree's skilled nursing facility. On 9/28/2021, Resident 2 fell at the courtyard and hit her head on the pavement and was bleeding. The facility dialed 911 emergency personnel. R2 sustained three staples on her head. Resident has returned to the community. There are two incidents concerning resident 3 (R3) on 10/8/2021 and 10/9/2021. It was reported on 10/8/2021 that R3 fell in the bathroom and sustained a laceration to her head. The facility called 911 emergency personnel and sent her to West Anaheim Medical Center. She returned to the community at 4:20 AM. On 10/9/2021, a nurse checked on R3 and found the resident was more lethargic and the 2 staples on her head was bleeding excessively. The nurse contacted 911 emergency personnel and the resident was taken to UCI Medical Center. R3 remains at Rowntree's skilled nursing facility. Resident 4(R4) fell in her room and had right hip pain and 911 emergency personnel was contacted. Resident was taken to Garden Grove Hospital. R4 sustained a hip fracture and is currently at Rowntree's skilled nursing facility. Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy was provided.the state’s words, verbatim · CDSS document, Oct 25, 2021

Allegation investigated: Resident sustained a fall while in care.

Licensing Program Analysts (LPAs), Kathrina Chin and Beverly Thompson-Gracia made an unannounced visit to the facility for the purpose of a complaint investigation. Upon arrival, LPAs met with Celeste Gonzalez, Administrative Assistant and spoke to Claudia Lusca, Executive Director on the telephone. The investigation consisted of interviews with the facility Administrator and reviewing and obtaining documentation. The following was determined: Resident 1 (R!) fell on September 30, 2021 and sustained a hematoma to the head. Resident was sent out to UCI Medical Center and returned to the facility the same day. The reporting party indicated that the fall was unwitnessed and there was no neglect on the part of the community. LPAs interviewed Claudia Lusca, Executive Director over the telephone and she indicated that this is the first time that R 1 needed to be sent out to the hospital due to a fall. Ms. Lusca indicated that 911 emergency personnel was contacted immediately after finding the resident sustained a fall. (Continued on LIC 9099C) Unfounded Resident 1 was seen by her primary physician on October 5, 2021 as a follow up to her fall and there were no changes made. The physician report indicated that R1's fall resulted possibly due to a stroke and hypertension. This agency has investigated the complaint and is determined to be UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted, and a copy of this report was given to Celeste Gonzalez, Administrative Assistant.the state’s words, verbatim · CDSS document, Oct 8, 2021 · control 22-AS-20211001105816

Type of visit: Office

At this informal conference present were Randy Brown, Executive Director; Michael Beeman, Chief Financial Officer; Pam Kaufmann, attorney; Mark Damon, Certified Public Accountant; Jim Stearman, attorney; Stan Leach, Licensee Board Member, Bill Hendrickson, CDSS Financial Consultant, William Young, Financial Analyst; Paramjit Judge, Financial Analyst; Marina Stanic, Licensing Program Manager; Allison Nakatomi, Manager; and Katie Anderson, Assistant Branch Chief. The informal conference process was explained to the Licensee. During the meeting the following was discussed with Licensee: - Clarifying line items in calculating the monthly burn rate. - Outstanding issues not addressed from last meeting. The following was agreed upon: - By August 24, 2021, CCLD will update the spreadsheet to reflect agreed upon methodology to calculate the monthly burn rate and will provide to the Licensee. * Operating Cash Inflow § Entrance fees (cash) received can be included § Donations can be included § Amortization must be deducted (if included in total revenue) § Non-recurring revenue must be deducted, such as grants or federal assistance (if included in total revenue) § Entrance fee refunds must be deducted * Operating Cash Outflow § Non-Cash Depreciation must be deducted § Non-recurring COVID 19 extra Expense can be deducted * Debt – Include payments made and do not include Line of Credit (if reporting debt payments here, those can be excluded from the expenses) - By September 7, 2021, Licensee will provide additional information to confirm the amounts for the grants, entrance fees and COVID 19 expenses as of June 30, 2021. - By September 7, 2021, Licensee will provide projections for the 12-month period for Balance Sheet and Statement of Cash Flows. The Department has the Profit and Loss with amended Corrective Action Plan (CAP). - By August 24, 2021, CCLD will provide the CAP Milestones template to be completed by the Licensee and returned to CCLD by September 7, 2021. - By September 7, 2021, Licensee will respond to clarify the “Other Strategies” identified in CAP: * Peer Consulting needs definition * Added Board Expertise * Management Consultant additional burden * Verify that Attorneys’ fees are captured in the budget Mark Damon (CPA) explained that his role is in an advisory capacity as an independent consultant and that the Licensee is responsible for all management decisions. An exit interview was conducted, and a copy of this report issued to the Licensee.the state’s words, verbatim · CDSS document, Aug 23, 2021

Type of visit: Office

At this informal conference present were Randy Brown, Executive Director; Michael Beeman, Chief Financial Officer; Pam Kaufmann, attorney; Mark Damon, Certified Public Accountant; Jim Stearman, attorney; Don Allen, Licensee Board Member; Ann Hablitzel, Licensee Board Member; Jeff Davis, Licensee Board Member; Stan Leach, Licensee Board Member, Bill Hendrickson, CDSS Financial Consultant, William Young, Financial Analyst; Paramjit Judge, Financial Analyst; Marina Stanic, Licensing Program Manager; Allison Nakatomi, Manager; and Katie Anderson, Assistant Branch Chief. The informal conference process was explained to the Licensee. During the meeting the following was discussed with Licensee: - unsound financial condition - board accountability (Title 22, Division 6, Chapter 8, Article 4. Operating Requirements, 87205 (a)(b) Accountability of Licensee Governing Body - short-term plan to ensure financial obligations are met - assistance from Foundation - bridge funding - sale of the J1 and J2 houses; expect gross proceeds of approximately $1.6 million - duration of compliance plan monitoring - agreement to cease offering Type A contracts - financial goals to break even or show 12 months positive results from operations prior to selling Type A or Type B continuing care contracts - restrictions put in place until short-term plan is met - possibility of updating Corrective Action Plan Continued on LIC 809C The following was agreed upon: - By August 13, 2021 the Licensee will inform the CCLD of the date CFH will receive report from their consultant, Crown Research and the date any updates to the Corrective Action Plan will be submitted. - Board Meeting scheduled for August 24, 2021 will authorize the sales of J1 and J2 Houses - Board Meeting Minutes will be forwarded to CCLD by COB September 3, 2021. - Draft compliance plan agreement will be submitted by the Department to the Licensee by August 20, 2021 and the parties will meet by August 27, 2021 to finalize the compliance plan. - The meeting with Licensee to review and discuss financial data is tentatively scheduled for August 20, 2021. - The repairs to the J1 house will be complete and the house will be ready to be listed for sale by August 31, 2021. The Licensee will inform the Department by COB August 25, 2021 of the date when J2 house repairs will be completed and the house ready to be listed for sale. - In the event that the facility runs out of cash prior to the sale of the home, the Licensee will have bridge financing pre-approved to meet immediate cash needs. The following items are going to be addressed at the meeting with the Licensee scheduled for August 20, 2021: - Projections for the 12-month period must also include Balance Sheet and Statement of Cash Flows projections. - Benchmarks and measurements of the compliance plan - Other Strategies in CAP not addressed in Amendment to Corrective Action Plan: - Peer Consulting - Added Board Expertise - Management Consultant and Attorneys’ cost An exit interview was conducted and a copy of this report issued to the Licensee.the state’s words, verbatim · CDSS document, Aug 11, 2021

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Kathrina Chin and Vicki Smith, Program Administrator and Kimberly Lewis, Assistant Program Administrator made an unannounced case management-incident visit at this Continuing Care Retirement Community and met with Kerri Clark, Director of Operations. Ms. Clark provided a tour of the CCRC campus such as the Independent Living, Assisted Living and Memory Care. During the visit, facility staff was observed to follow the mitigation plan and has sufficient PPE supplies. No deficiency observed this review as per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to Kerri Clark, Director of Operations.the state’s words, verbatim · CDSS document, Jul 20, 2021