Samaritan Village

Type of visit: Required - 1 Year

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct an annual inspection, LPA met with administrator Rikki Perezchika to explain purpose of visit. LPA interviewed the facility designated back of the house supervisior and toured the kitchen. foods stored are in a servable quality and a quantity of at least 2 days perishable and 7 days non perishable. the kitchen is free of insects and pests to the LPA's observation. approprite storage temps of 0c, 40F, for firdges and freezers. emergency food supply is present for at least 1200 meals. LPA did not observe a meal service. LPA reviewed the most recent consultant report from nutricopia(nutrition), no concerns at this time. LPA interviewed the facility manager and housekeeping supervisor. LPA toured the grounds: 5/5 residents rooms with hardware in repair, with required bedroom furnishings and furniture. LPA observed o2 signs posted for relvant clients, some clients have cameras within thier room with signage. LPA gave guidance the facility should not have access to that footage, as any facility owned/operated cameras should be public areas only(no bedrooms, no bathrooms) and video only. Egress bars exiting the assisted living/memory care unit have a 45 second timer, LPA gave guidance that the regulation standard is 30 seconds but a waiver would probably granted for times less than 60 seconds. LPA reviewed the 6 most recent pesticide consultant reports from Clark(pest control), no concerns at this time. LPA interviewed the med managment supervisior, and toured 2 of the med rooms. LPA reviewed medical records of 4 clients for compliance with reporting requirements of refusals, PRN distribution, Medication destruction, and controlled substances logs. The LPA gave best practices to have flexibility with the check times on prn distribution, newer medications should be assessed for effectiveness sooner than an hour. LPA asked the facility to produce a camoflauge consent form for crushed medication, for the event where one of the clients with a crushed medication order graduates from hospice. LPA did not observe a med pass. LPA reviewed the most recent medication storage consultant report from OMNICARE(med storage), no concerns at this time. Continued on c page LPA Interviewed 1 care staff, 1 medtech, and 1 administrator. LPA interviewed 4 clients. LPA reviewed 8 client files, for recent 602s, needs and services plans, health screenings, and signed admission agreements. all files present and up to date. where applicaple, hospice care plans were reviewed. LPA gave guidance to call for appropriate emergency medical services if the need is outside the care condition of the hospice care plan. LPA gave guidance that exception requests may be necessary for clients who graduate from hospice, and the LPA recommends a self audit of the client files for clients with restricted care conditions not covered by hospice who might need exeption paperwork.. LPA reveiwed 6 staff files, for recent and initial trainings, first aid/cpr certification, health screenings, and background checks. all files are present and up to date. LPA reviewed the facility/administrator files, including but not limited to the 610, 400, and infection control plan. The facility's alarm system is functional, and was tested with 27 second response time. The fire extinguishers are dated 3.6.26. Fire and Co alarms are functional. Recent disruptions to power from a broken panel are now resolved. no citations associated with this visit, a copy of the report was read and given to the administrator, exit interview was conducted.the state’s words, verbatim · CDSS document, Aug 28, 2026

Allegation investigated: Staff does not ensure resident is spoken to in an appropriate manner

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct an investigation into the above allegation. LPA met with rikki perezchica to explain the purpose of the visit. It was claimed by a annonymous party that a resident was in the care of a staff for 1:1 end of life care when the resident verbally expressed thier displeasure with the staffs ability to provide basic assistance repositioning, changing the channel, and the staff is alleged to have returned with a inapproporite remark and then not providing care to the resident for a durration of the her shift. LPA interviewed connected parties (staff and residents) to the alleged staff: hca manager, shift lead, medtech coworker on shift, residents under the care of the alleged staff. concensus statement was reached that none but the victim and the alleged staff witnessed the alleged behavior, a concensus was not reached about the likelihood of the alleged staff to speak in a rude manner to the resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.A copy of the report was read and given to the administrator. an exit interview was conducted. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 20, 2026 · control 27-AS-20260527160042

Type of visit: Case Management - Other

On 11/04/2024, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced regarding a case management. LPA Campbell asked for the file for Resident 1 (R1) and reviewed the Incident Report (IR) for the incident that occurred on 10/27/2025. Per the SCO 341, R1 called the front desk and asked for assistance and R1 stated had taken poison on purpose. When staff arrived, R1 stated they did not remember why had taken the hydrogen peroxide. When S1 asked why they had taken the hydrogoen peroxide, R1 said they had done it on purpose. The hydrogen peroxiide bottle was empty by the sink and the aspirin bottle was empty on top of the trash. 911 was called. When they arrived, EMS asked what the resident had done but R1 was unable to recount what happened.. R1 was also unable to tell the hospital when they arrived, what they had done . R1's son and physician were notified and R1 was taken to the hospital. R1 was an independent living resident and did not need assistance with activities of daily living. (ADL). Per the most recent Physician's Report, R1 had a diagnoses of Depression with a secondary diagnoses of Mild Cognitive Impairment. The Mild Cognitive Impairment addition came on 03/2025. However, there was no change in the Physician's Report regarding restrictions for medication or other as needed drugs or chemicals. Treatment consisted of two rounds of dialysis that were completed successfully at the hospital. Afterwards, the hospital determined R1 needed Memory Care which Samaritan does not provide. Along with Samaritan Viillage and a placement agency, a more appropriate facility was found. Once transferred to the new facility, R1's son reported that R1 had stated she had taken three aspirin and had used Hydrogen Peroxide for her hair. Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 8, no deficiencies are being cited.the state’s words, verbatim · CDSS document, Nov 4, 2025

Type of visit: Required - 1 Year

At approximately 8:30 am, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct an annual inspection. Upon entry, LPA Campbell observed residents going in and out of the entrance of the community mall area. Once LPA Campbell identified themselves, staff notified the administrator. Once the administrator arrived, LPA Campbell explained the purpose of the visit and the administrator stated they would find a meeting room available for LPA Campbell's use. Once a meeting room was found, LPA Campbell requested a list of residents and staff to select from for a random file review. The facility is licensed to serve 277 residents. Of those residents, 15 of them may be hospice residents. The facility has delayed egress and a dementia unit for 30 residents. Each resident room has its own bathroom and temperature control. LPA inspected the physical plant including but not limited to kitchen, bathrooms, and activity areas. LPA Campbell observed that there was sufficient furniture and lighting throughout the facility. LPA Campbell measured the water temperature for two rooms. One was inhabited and the other vacant. When testing the water in the vacant room, the hot water side was labeled incorrectly The administrator stated they would contact maintenance to make the correction. During a tour of the kitchen, LPA Campbell observed sufficient seven day non-perishable and two day perishable food supplies. Items in the freezer and refrigerator were covered or sealed. The menu for the month was displayed in the kitchen and LPA Campbell observed the items from the menu being served in the dining room for the correct date. The temperatures for common areas were set at 74 degrees which is between the required 68 to 85 degrees limitation for Residential Care Facilities for the Elderly (RCFE). Omni care was contracted by the community to conduct a quarterly audit of medication, storage of medications, central storage logs and destruction records that was last completed on July 29, 2025. A Review found that the community met a 100% compliance of all items audited. LPA Campbell requested and attempted to review 10 resident files and 6 staff files. All files reviewed were found to be complete. The Administrator provided the most recent Certificate of Liability Insurance form for 06/14/2025 to 06/14/2026. Fire drill logs for January, March and May were reviewed as well. Fire extinguishers are current and in compliance with fire safety. Per California Code of Regulations, Title 22, no deficiencies were observed during today’s visit. A copy of this report was provided to the facilitythe state’s words, verbatim · CDSS document, Aug 13, 2025

Type of visit: Required - 1 Year

On 09/12/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility unannounced to complete an annual inspection. LPA Campbell met with Administrator Rikki Perezchica and explained the purpose of the visit. The facility has a capacity of 277 clients. There is a hospice waiver for up to 15 residents, and a dementia unit that holds up to 30. The main facility consists of administrative offices, the main kitchen and dining room, chapel and residences for Assisted Living clients. There is also a private dining rooms on both the 2nd and 3rd floors. Upon entry, LPA Campbell observed residents participating in a religious service in the facility chapel. Other residents were socializing with each other at the front desk and in passageways. There are currently 170 clients and 130 staff. Of the 170 clients shown in the roster, LPA Campbell selected 8 random names from the client roster to be pulled for review. Of the 140 staff listed on the staff roster, LPA Campbell selected 8 random files to be pulled. Of the files reviewed, none were found to have deficiencies. After consultation with the Administrator, LPA Campbell suggested that LIC 9052 be used to ensure the Employee Rights section of the facility handbook provided to staff is complete. During a tour of the facility, LPA Campbell visited the kitchen, dining room, residents rooms and the emergency food storage room. There was enough food found in the non-perishable pantry room and the emergency food storage room to supply the facility with sustenance for 7 days and enough perishable foods found in the refrigerators to last 3 days. The refrigerators were set at 36 degrees Fahrenheit and the Freezer was 0 degrees Fahrenheit. The floors of the cold storage rooms were clear of debris. On the third floor, another dining room was found. On the door of the dining room, there was a menu for the month of September. Chef Specials were listed daily on the calendar and Weekly Featured Specials were found on the bottom of the menu. LPA Campbell toured two rooms of the facility and found the necessary furniture and accessories. Each room has its own thermostat and could be set by the resident.. The hot water was in the bathroom of a resident was measured at 115 degrees Fahrenheit which meets the requirement of at least 105 degrees Fahrenheit, and not more than 120 degrees Fahrenheit. In lieu of a smoke alarm test, the administrator provided proof of a yearly Fire System Inspection completeted on 09/27/2023. Fire extinguishers were last inspected on 03/04/2024 LPA Campbell observed an Emergency Response System in use throughout the facilities in clients rooms and in hallways as a signal system. Later while speaking with the Administrator, the sound from the signal system could be heard from a staff members radio. The administrator was cleared to work in the facility and they provided proof that they had submitted their application for renewal of their administrative certificate. The certificate expired 06/23/2024 and the administrator applied for renewal on 05/30/2024. Due to contradictory directions found on form LIC9214 Application for Administration for Certification, no deficiency was cited. Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted with Rikki Perezchica and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 12, 2024

Type of visit: Case Management - Health Checks

On 05/03/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility at approximately 8:45 am to follow up on the status of a city boil order. Upon arrival, LPA Campbell observed residents moving about and socializing. Water dispensers were observed available to residents, staff and guests. On 04/26/24, LPA Campbell received an Unusual Incident Report from the facility that the City of Hughson was under a Boil Notice. LPA Campbell reviewed the memo and city announcement submitted to the residents. City residents were not to drink or use the water for food preparation without boiling. Samaritan Village informed the Department that the facility had 72 hrs of water supply. The Boil Notice ended the next day on 04/27/24 and the city notified Hughson citizens that testing had confirmed that the water was safe to use without boiling. As stated by Administrator Rikki Perezchica, the city stated a well had depressurized and contaminated the water. The notice came from the city on Saturday that water could be used without boiling again. However, the facility did not come online until Sunday and used the extra day to flush the pipes. The kitchen removed all the ice and disinfected the water lines. During that time, ice was replaced, canned sodas were provided, and coffee was not served. Water use returned to baseline by Sunday morning. The administrator also reported that the facility planned ahead for the boil notice to go on for an additional two days. To that end, the facility had three bins that are not connected to any water source that are filled and maintained to make sure there is water. In addition there were 5 gallon water dispensers that were spread around the campus for residents. More water bottles were also purchased in anticipation of a four day delay up until Tuesday. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's visit. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, May 3, 2024

Type of visit: Case Management - Incident

On 02/01/2024, Licensing Program Analyst Renee Campbell arrived at the above facility at approximately 9:30 am. LPA Campbell met with Kaylie McCortney and Administrator Rikki Perezchica and shared the purpose of the visit. The purpose of this case management visit was to follow up on the Incident Report (IR) submitted by the facility on 12/18/23. Per the Incident Report, expired insulin (exp. 12/12/23) was discovered by a Med Tech during the medication pass procedure. The 602, IR and MAR for R1 were observed by LPA Campbell. As a result of this visit, it was determined that the facility followed reporting regulations and the following deficiencies and plan of correction were observed (see LIC 809-D for deficiencies cited). Exit interview with Staff Appeals rights printed.the state’s words, verbatim · CDSS document, Feb 1, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Feb 6, 2024

Incidental Medical and Dental Care 87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by : Based on a record review, observation and interviews, staff did not verify the expiration date for the insulin before providing it to the resident. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 1, 2024

Plan of correction: The Medication Management Supervisor removed the responsible staff from the Med Tech position and now requires supplementary documentation for medication to be added to the electronic MAR. POC completed during visit as observed by LPA Renee Campbell

Type of visit: Case Management - Incident

On 12/04/2023, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to this facility to conduct a case management visit. LPA met with Administrator, Rikki Perezchica and explained the purpose of the visit. Current Census was 177. The purpose of this visit was to follow up on a Medication Error incident Report on 10/26/23 and several reports of falls that occurred between 11/04/23 and 11/07/23. LPA Campbell interviewed the Administrator and Medical Technician LPA Campbell conducted interviews and reviewed facility documentation. The Unusual Incident Report received by the department on 10/26/23 states that a resident received a medication in error. The resident was later admitted to the hospital that same night due to severe constipation. Though it is unknown if this was due to the medication error. LPA Campbell reviewed the residents MAR for the date of the incident. It was learned that the Medication Technician admitted that the error was due to her inattention. An internal investigation was conducted and the MT involved underwent procedural retraining that included the 6 Rights of Medication, shadowing and a Medication Management Competency Quiz. The MT has not experienced further medication errors per the administrator. The Unusual Incident Report received by the department between 11/04/23 and 11/07/23 involved several resident falls. LPA Campbell reviewed the incident reports, progress notes and service plans for the residents involved. Of the falls recorded, there was no common denominator. Residents fell due to a refusal to follow their care, because they were in need of a change in their care plan or because the resident experienced a one time fall after tripping. It was learned that the facility provided all residents a fall risk re-evaluation according to the facility Fall Policy and adjustments in their care plans were made as needed. Based on the information gathered during today's visit. No deficiencies are being cited. An exit interview was conducted and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 5, 2023

Type of visit: Required - 1 Year

Unannounced annual visit made out to this facility on 09/28/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility Care Operations Manager Kaylie McCortney since the facility designated Administrator, Rikki Perezchica, was unavailable at this time. A brief interview was conducted with the facility representative, Kaylie McCortney, at this time. It was learned that there were residents under the care of hospice(9) at this time while other residents were receiving services through home health (15) as well. This facility does have a hospice waiver approved for (15) residents and fire cleared for bedridden (2) and dementia care for residents at any given time. Current census was 180 residents. A tour of this facility was conducted alongside the facility Care Operations Manager. Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator. Kitchen area was toured. Cabinets and drawers were reviewed. Food preparation stations, dishwashing station, and other areas intended for meal preps were toured. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe additional food storage units which were present and functional at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication room, located on the first floor, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications were discussed with the facility designated medication technicians at this time. The medication carts were observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restroom was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. It was learned that there were (7) different floor plans for residents on the Assisted Living portion of this facility. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Linen closet, located in the facility laundry area, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time. This facility does not have a dedicated Memory Care unit at this time. Dementia diagnosed residents are integrated into the main census of Country Manor. Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 03/02/2023 by the local fire extinguisher company, Cisco Fire and Sprinkler, and in compliance at this time. First aid kits were observed to be present and contained all of the required components at this time. Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gates, and exits was conducted. A review of (5) facility resident files was conducted. A review of (5) facility personnel files was conducted. The following forms and documents were requested to be updated and submitted into CCL: LIC 308 LIC 400 LIC 500 LIC 610 The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal Rights were printed and a copy was given to the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Sep 28, 2023