San Clemente Villas by the Sea

Type of visit: Annual/Random

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit to San Clemente Villas by the Sea. The purpose of today’s visit was to conduct the Annual Required inspection. LPAs were allowed entry into the facility and explained the reason for the visit. Facility is licensed for 190 ambulatory of which 120 may be non-ambulatory and 40 bedridden. Facility has an approved hospice waiver for 20 residents and the facility currently has 10 residents on hospice care. Kimberly Malaspina has an administrator certificate expiring on 12/30/2027. LPAs Lyman and Mendivil along with Administrator Malaspina toured the facility at 9:27 AM. LPAs toured the physical plant, checked food service, facility records and the first aid kit. Facility consists of a four story building including assisted living and memory care. Throughout the building, LPAs observed kitchen, dining room, activity areas, gym, movie theater and beauty salon. Resident apartments had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 106 and 116.2 degrees F in facility restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Staff responded within 5 minutes for emergency pull. First aid kit had required elements including thermometer, tweezers and scissors. LPAs observed no unsecured toxins. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Temperature logs were complete and within range. Smoke detectors are tested quarterly in house and fire inspections are conducted by an outside company, Fire Service Corporation with the last inspection on 02/17/2025. The next fire inspection is pending completions of the last of the facility renovation. Fire extinguishers are fully charged. LPAs observed evacuation chairs at stairwells CONTINUED ON LIC 809C DATED 08/27/2026 LPAs toured the outside grounds and there is ample shaded seating for residents. There is a fenced pool secured with a lock which is out of service today. LPAs observed emergency food and water. LPAs reviewed the emergency disaster plan and infection control plan during the visit. Plans are thorough and complete. Facility conducts monthly emergency drills with the last drill conducted on 07/16/2026. Facility provides activities in the form of games, exercise, and outings in the community. LPAs observed residents participating in activities during the visit. At 11:15 AM, LPAs reviewed select resident and staff files. Resident files contained required documents including admission agreements, current physician reports and resident appraisals. Staff files reviewed contained required documentation such as health screen/TB and criminal record clearance. Six out of six staff do not have proof of required annual training. LPAs observed six out of six staff do not have CPR training. LPAs reviewed medication administration and storage. Medications are stored in a locked medication cart. Medications appear to be administered per physician order. Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided as well as appeal rights.the state’s words, verbatim · CDSS document, Aug 27, 2026

Allegation investigated: Staff engaged in inappropriate behavior with resident(s)

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff. Regarding the allegation that staff engaged in inappropriate behavior with resident(s), the investigation revealed the following: Resident 1 (R1) has a known action of inappropriate behavior and facility is working with the resident's physician to address the issue. Five out of five staff indicate the resident is the instigator of inappropriate behavior and not the staff. Facility staff indicates staff are going in pairs to the resident's room to ensure safety for the caregivers/ med techs. Per Service Plan Report dated 06/01/2026, R1 is diagnosed with Schizoaffective Disorder. Based on interviews conducted, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was left at the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 22, 2026 · control 22-AS-20260720080427

Allegation investigated: Staff are mismanaging residents medication

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the memory care unit and interviewed staff as well as reviewed and obtained pertinent documentation such as medication administration records. Regarding the allegation that staff are mismanaging residents medication, the investigation revealed the following: LPA toured the memory care unit and did not observe any medications on the ground in common areas or in resident rooms. LPA reviewed select medication administration records (MAR) and did not observe any discrepancies. Five out of six staff deny medications or supplements lying on the ground. One out six staff stated finding a vitamin on the ground one time. Based on interviews conducted, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was left at the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 22, 2026 · control 22-AS-20260706093007

Allegation investigated: Facility is not kept at a comfortable temperature. Areas of the facility are in disrepair with exposed wires.

Regarding the allegation: Facility is not kept at a comfortable temperature During the investigation 0 of 7 individuals were able to provide any corroborating information or evidence to support the complaint allegation as reported. Multiple individuals denied the allegation. One individual claims the temperature in the facility is not too cold and not too hot. Regarding the allegation: Areas of the facility are in disrepair with exposed wires. During the investigation 0 of 7 individuals were able to provide any corroborating information or evidence to support the complaint allegation as reported. Multiple individuals acknowledged the facility is making some renovations to different areas of the building. Multiple individuals denied the elevator is in disrepair. One individual stated although there's some construction taking place, the facility is in good repair. Continued on LIC9099C Unsubstantiated Another individual who denied the elevator was in disrepair claims the facility is in good repair and the facility has a good maintenance team. One individual did confirm a button for a service elevator was not working properly;however, the service elevator was still operational. The individual explained the button was fixed in a day or two. The residents were not affected as the two resident elevators were still operational. Based on the information gathered during the investigation through interviews and observation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the allegations are deemed unsubstantiated.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 22-AS-20250130104434

Allegation investigated: Thermostat's in memory care resident's rooms are not properly secure.

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to complete the investigation and deliver findings on the allegation listed above. LPA was greeted and granted entry by staff after explaining the reason for the visit. Regarding the allegation: Thermostat in memory care resident’s rooms are not properly secure During the investigation 6 of 7 individuals confirmed the complaint allegation. According to Executive Director Paoli, Resident 1 (R1) was found on the floor in their room with the thermostat turned all the way up. Another individual confirmed R1 turned up their thermostat and was found on the floor conscious and the room was hot. Another individual explained that other residents have adjusted the temperature on their thermostat and the facility placed covers on the thermostat once discovered residents were adjusting them. Continued on LIC9099C Substantiated The individual explained that a cover was recently placed on the thermostat in R1's room. During the investigation it was confirmed the thermostat in R1’s room was the last one without a safety cover, and the cover was not placed on the thermostat until after R1 was found on the floor of their room with the thermostat turned all the way up. Based on the evidence gathered through interviews and document review the preponderance of evidence standard has been met, therefore, the above allegation is found to be substantiated. Violations are being cited per California Code of Regulations Title 22. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 22-AS-20250130104434

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(e)(1)(A) · Plan of correction due date: Jul 17, 2026

87307 Personal Accommodations and Services (e) The licensee shall supervise residents as needed and as determined by the resident's appraisal... when residents are in proximity to or when there is use of the following items: (1) Ranges, ovens, heaters, fireplaces, wood stoves, inserts, and other heating devices. (A) Heating devices shall have protective mechanisms or other measures to prevent access to the device, or to make it inoperable when not in use, in order to reduce the risk of burns or fire. This requirement was not met as evidenced by: It was discovered R1 did not have a cover on their thermostat in their room. R1 was sent to the hospital after being discovered on the floor of their room and with the thermostat turned all the way up. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2026

Plan of correction: Executive Director Malaspina will confirm all 22 resident rooms in the Memory Care unit have a cover placed over the thermostat. Executive Director Malaspina will email LPA Haley confirming all rooms have a cover by 1:00pm on the POC due date. LPA Haley verified R1's room does have a cover over the thermostat during the visit.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to follow up on an incident report received by the department on 05/29/2026. LPA was greeted and granted entry into the facility and explained the reason for the visit. Incident report dated 05/15/2026 indicated Resident 1 (R1) had been discovered by an off duty caregiver in the parking lot of Ralph's approximately .2 miles from the facility. Caregiver transported the resident back to the facility with no adverse effects. Physician report dated 03/19/2026 indicates resident is diagnosed with Dementia and has elopement as a behavioral expression. The physician report states the resident is unable to leave the facility unassisted. Staff were unaware the resident had eloped out of the memory care unit. Based on the observations made during today’s visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided as well as appeal rights.the state’s words, verbatim · CDSS document, Jul 9, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jul 10, 2026

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interview conducted and record review, Licensee failed to ensure basic services was provided to R1. R1 eloped out of the facility and was found by off duty staff which poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Jul 9, 2026

Plan of correction: Licensee conducted an in-service on 05/19/2026. CLEARED DURING VISIT.

Allegation investigated: Staff do not ensure that residents are administered their medications as prescribed Staff mismanage residents' medications

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the memory care unit and interviewed staff as well as reviewed and obtained pertinent documentation such as medication administration records (MAR). Regarding the allegations that staff do not ensure that residents are administered their medications as prescribed and staff mismanage residents' medications, the investigation revealed the following: LPA toured resident rooms and memory care unit on two different occasions and did not observe any medications in rooms or common areas. Four out of five staff deny finding medications lying around. One staff stated finding a medication in the dining room one time. LPA reviewed the MAR for five residents. All five MAR's have documented reasons for missed medications. Resident 1 (R1) is not prescribed a GLP medication per MAR. Based on record review and interviews conducted, LPA is unable to corroborate the allegations. CONTINUED ON LIC 9099C DATED 05/14/2026 Unsubstantiated Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, May 14, 2026 · control 22-AS-20260421085522

Allegation investigated: Staff member worked while under the influence of drugs, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the memory care unit and interviewed staff. Regarding the allegation that staff member worked while under the influence of drugs, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care, the investigation revealed the following: Five out of five staff interviewed deny any knowledge of a staff being present under the influence. Five out of five staff deny any staff sleeping in the facility before their shift. Administrator indicates no knowledge as well and confirms there have been no write-ups or terminations for this type of behavior. Based on interviews conducted, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 14, 2026 · control 22-AS-20260420154329

Allegation investigated: Facility gave resident another resident's psychotropic meds which resulted in hospitalization

Licensing Program Analyst (LPA) Kimberly Lyman conducte an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, the department reviewed and obtained pertinent documentation such as facility notes. Regarding the allegation that facility gave resident another resident's psychotropic meds which resulted in hospitalization, the investigation revealed the following: Facility self reported an incident on 09/04/2024 where Resident 1 (R1) was incorrectly given another resident's Seroquel, Risperidone, and Lorazapam. R1 was transferred to Mission Hospital for observation and remained admitted until 09/08/2024. Facility notes indicate Mission Hospital stated there were no adverse effects from the medication error. Staff 1 (S1) was provided a written warning from the facility. Review of records showed the staff had received medication training from the facility. Based on record review, the preponderance standard has been met. Therefore the allegation is deemed substantiated. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of the report provided as well as appeal rights. Substantiatedthe state’s words, verbatim · CDSS document, Apr 9, 2026 · control 22-AS-20240923110559

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 10, 2026

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). Based on record review, Licensee failed to ensure care and supervision was provided to R1. R1 received three medications belonging to another resident and was hospitalized for observation. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: Licensee to conduct an in-service on administering medications and forward proof to LPA by POC due date.

Allegation investigated: Staff do not communicate changes in care to authorized representative Staff not providing records to the authorized representative

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. Long Term Care Ombudsman Patricia McKeon was present as well. During the visit, LPA interviewed Administrator as well as reviewed and obtained pertinent documentation such as facility notes. Regarding the allegations that staff do not communicate changes in care to authorized representative and staff not providing records to the authorized representative, the investigation revealed the following: Resident 1 (R1) was re-assessed on 03/24/2026 and 04/01/2026 after two instances of elopement out of the facility in March 2026. Per physician reports dated 10/02/2022 and 03/24/2026, R1 is diagnosed with Mild Cognitive Impairment and unable to leave the facility unassisted. Both assessments were provided to responsible party and time stamps on documents confirm the documents were provided. Facility administrator confirms a care plan meeting was conducted with responsible parties on 03/26/2026. LPA reviewed facility documentation outlining the care plan. Email CONTINUED ON LIC 9099C DATED 04/09/2026 Unfounded correspondence indicates responsible party was informed of the care companion facility implemented. Email correspondence dated 04/03/2026 show additional requested documents were provided to the responsible party including incident report and updated physician report. Based on record review and interviews conducted, the allegations are deemed UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 22-AS-20260402125930

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident reports submitted to the department. LPA was greeted and granted entry into the facility and explained the reason for the visit. Incident report dated 03/18/2026 indicated Resident 1 (R1) left the facility around 7:00 PM and returned at 9:40 PM. Resident was assessed and no injuries noted. Resident was noted to be exit seeking and was provided a wander guard on 03/17/2026 however the resident removed the device. Resident is on the facility elopement list at front desk as unable to leave the facility. There are staff present at front desk until 9:00 PM. Incident report dated 03/24/2026 indicated R1 had eloped out of the community and was returned to the facility by a bystander who observed the resident outside the facility. Resident returned at 3:00 PM. It is unknown what time the resident left. Facility placed a one on one companion with the resident and a care plan will be conducted for next steps with resident. Resident is diagnosed with MCI and physician reports dated 10/02/2022 and 03/24/2026 show resident is not allowed to leave the facility unassisted. Resident had a prior elopement in December 2022. LPA observed the resident sitting on a bench near the facility exit without the one on one companion. LPA spoke with resident who stated was going to be leaving for a medical appointment with family. Based on the observations made during today’s visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided as well as appeal rights.the state’s words, verbatim · CDSS document, Apr 1, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 2, 2026

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on record review and interviews conducted, Licensee failed to ensure care and supervision was provided to resident. R1 eloped two times out of the facility on March 18 and 24, 2026 which poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSEDthe state’s words, verbatim · CDSS document, Apr 1, 2026

Plan of correction: Licensee to conduct an in-service on resident elopements and forward proof to LPA by POC due date.

Allegation investigated: Facility is charging a resident for services not rendered

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and residents. Regarding the allegation that facility is charging a resident for services not rendered, the investigation revealed the following: Information reported to the department indicated Resident 1 (R1) is being charged for dressing assistance. LPA reviewed resident assessment dated 12/17/2024 which showed that the resident is not being charged for dressing. Resident and staff denied staff are assisting with dressing. Based on record review and interviews conducted, the allegation is deemed UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility. Unfounded Administrator states providing notices to residents and families regarding water and electric shut offs. LPA toured the facility on three different occasions and observed precautions in place to minimize disturbances to residents. Facility has blocked off areas where construction is taking place. Based on observations and interviews conducted, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Sep 12, 2025 · control 22-AS-20250619121530

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 08/21/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87555(b)(8) pertaining to Food Services has been cleared. Licensee provided proof of correction. Licensee has complied with the terms of the POC. *Deficiency cited under Title 22 Regulation 87411(f) pertaining to Health Screen/ TB has been cleared. Licensee submitted proof of correction. Licensee has complied with the terms of the POC. *Deficiency cited under H & S Code 1569.625(b)(2) pertaining to Staff Training has been cleared. Licensee provided proof of training. Licensee has complied with the terms of the POC. *Deficiency cited under Title 22 Regulation 87705(f)(2) pertaining to Care of Persons with Dementia has been cleared. Licensee has provided proof of correction. Licensee has complied with the terms of the POC. Licensee has been advised to maintain all items previously cited in compliance. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 12, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kimberly Lyman and Fred Arias conducted an unannounced visit to San Clemente Villas by the Sea. The purpose of today’s visit was to conduct the Annual Required inspection. LPAs were allowed entry into the facility and explained the reason for the visit. Facility is licensed for 190 ambulatory of which 125 may be non-ambulatory and 40 bedridden. Facility has an approved hospice waiver for 20 residents and the facility currently has 11 residents on hospice care. Fred Paoli has an administrator certificate expiring on 04/17/2026. LPAs Lyman and Arias along with Administrator Paoili toured the facility at 9:09 AM. LPAs toured the physical plant, checked food service, facility records and the first aid kit. Facility is currently under renovation with the third floor closed to residents. Facility consists of a four story building including assisted living and memory care. Throughout the building, LPAs observed kitchen, dining room, activity areas, gym, movie theater and beauty salon. Resident apartments had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 107.9 and 119.3 degrees F in facility restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Staff responded within 10 minutes for emergency pull. At 9:30 AM, LPAs observed the gates in the memory care patio are locked with a key and do not have the approved delayed egress on the gate. First aid kit had required elements including thermometer and scissors. LPAs observed no unsecured toxins. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPAs observed multiple items out of date including yogurt, milk and cream. CONTINUED ON LIC 809C DATED 08/21/2025 Smoke detectors are tested quarterly in house and fire inspections are conducted by an outside company, Fire Service Corporation with the last inspection on 02/17/2025. Fire extinguishers are fully charged. LPAs observed evacuation chairs at stairwells. LPAs toured the outside grounds and there is ample shaded seating for residents. There is a fenced pool secured with a lock. LPAs observed emergency food and water. LPAs reviewed the emergency disaster plan and infection control plan during the visit. Plans are thorough and complete. Facility conducts monthly emergency drills with the last drill conducted on 07/17/2025. Facility provides activities in the form of games, exercise, and outings in the community. LPAs observed residents participating in activities during the visit. At 11:15 AM, LPAs reviewed select resident and staff files. Resident files contained required documents including admission agreements, current physician reports and resident appraisals. Staff files reviewed contained required documentation such as health screen/TB and criminal record clearance. One out of six staff do not have a health screen/ TB. Six out of six staff do not have proof of required annual training. LPAs reviewed medication administration and storage. Medications are stored in a locked medication cart. Medications are being administered per physician order. Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided as well as appeal rights.the state’s words, verbatim · CDSS document, Aug 21, 2025

Allegation investigated: Staff communicate in a language that residents are unable to understand Staff are mismanaging residents' medications

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to continue the investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the memory care unit and interviewed staff. Regarding the allegations that staff communicate in a language that residents are unable to understand and staff are mismanaging residents' medications, the investigation revealed the following: Facility Executive Director indicates staff are to speak to residents in a language they are able to understand. Most speak English to residents but Spanish speaking residents prefer the staff speak Spanish with them. Eight out of nine staff state residents are able to understand the staff and there is no issue with language. Staff 1 (S1) indicates the language barrier is directed at the staff and not the residents. LPA unsuccessfully attempted interviews with memory care residents regarding the allegations. LPA spoke with nine staff and did not have any difficulties communicating with any of the staff. LPA observed residents being assisted and did not observe any concerns regarding language. CONTINUED ON LIC 9099C DATED 06/03/2025 Unsubstantiated Eight out of nine staff deny finding medications on the floor or in resident rooms. Staff state watching residents take their medication to ensure they are taken. LPA toured the memory care unit on two different occasions and observed no loose medications. Based on records reviewed and interviews conducted, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Jun 3, 2025 · control 22-AS-20250424120311

Allegation investigated: Staff are not providing timely access to a resident's personal records.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the initial investigation into the allegation listed above. LPA was greeted and granted entry by front desk staff after introducing himself and stating the purpose of the visit. Executive Director Fred Paoli was present and assisted with the visit after being presented with the allegation under review. During the visit, LPA requested and obtained the facility's current resident census, staff roster along with records maintained at the facility for resident R1. One staff interview conducted. CONTINUED ON FORM LIC9099-C Substantiated CONTINUED FROM FORM LIC9099 Per the records reviewed along with the death report submitted by the facility on May 10, 2024, R1 passed away under hospice continuous care on April 28, 2024. On or around February 26, 2025, a law firm representing the late resident reached out to facility staff to request records from R1's period of admission at the facility. Per facility staff, records were not submitted in response yet after a follow-up email was sent during the week of March 9 to March 15, 2025. Facility staff indicated that a facility audit on the records requested was under way and had delayed the submission of records. Per the documentation reviewed, the law firm made the request and submitted all supporting evidence to demonstrate the request was legitimate, as well as issued a payment for clerical and reproduction costs by check dated February 25, 2025. Per Title 22 regulations, "Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.". Based on the evidence gathered, facility staff failed to meet that requirement. The allegation that "Staff are not providing timely access to a resident's personal records" is therefore substantiated, meaning that the preponderance of evidence standard has been met. A type B deficiency is cited on an attached form LIC9099-D. An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.the state’s words, verbatim · CDSS document, Mar 18, 2025 · control 22-AS-20250313134523

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Mar 31, 2025

Per the California Code of Regulations Section 87468.2(a)(19) listing Additional Personal Rights of Residents in Privately Operated Facilities: "residents(....) shall have all of the following personal rights: (...) (19) To have prompt access to review all of their records (...) Photocopied records shall be provided within two (2) business days (....)". This requirement was not met as evidenced by the additional delay evidenced during the present visit. This constitutes a potential risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Mar 18, 2025

Plan of correction: Facility staff will inform LPA that records requested have been provided before the plan of corrections due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report received by the department on 02/25/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit. Incident report dated 02/13/2025 indicated Resident 1 (R1) had an un-witnessed fall in the hallway and was observed to have hip pain. 911 was called and resident was transported to the hospital and was diagnosed with right hip fracture. Resident had surgery to repair hip and admitted back to the facility on 03/01/2025. Per physician report dated 11/05/2024, resident is diagnosed with Dementia. Resident assessment dated 01/31/2025 indicates fall concern. LPA observed no other documented falls. Administrator states resident is on frequent checks, four times per shift, when not in common area of memory care unit. LPA viewed the area where the fall took place and observed no concerns. LPA spoke with resident who appeared well taken care of and verbalized feeling safe at the facility. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 12, 2025

Type of visit: Collateral

On today’s date Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced collateral visit while conducting initial visit into investigation Control Number 22-AS-20250220115306. LPA met with Business Office Manager Sharon Gerken and explained reason for visit. During today’s visit, LPA Tirre toured facility and collected pertinent documents such as facility staff roster, resident roster and Resident 1 record file. Exit interview conducted with Business Office Manager Sharon Gerken and copy of report was provided.the state’s words, verbatim · CDSS document, Feb 21, 2025

Allegation investigated: Facility is not providing care and supervision to residents Incontinence care is not being provided to residents

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to continue the investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the memory care unit and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as facility notes. Regarding the allegations that incontinence care is not being provided to residents and facility is not providing care and supervision to residents, the investigation revealed the following: Five out of five staff state incontinence care is provided at least every 2 hours and residents are not left soiled. All staff interviewed state no incidents of coming on shift and finding a resident soiled. Two out of five staff state instances of working with only one other person making care to residents difficult. LPA toured the memory care unit on two different occasions and observed all residents had blankets and temperatures were between 71-75 degrees F in resident rooms. LPA interviewed Resident 1 (R1) who stated he received his pendant when he moved in and that staff respond to the pendant timely. CONTINUED ON LIC 9099C DATED 02/10/2025 Unsubstantiated Facility documentation indicates that R2 was sent out to the hospital on 12/18/2024 due to abdominal pain. Resident has been out of the facility since then admitted to a skilled nursing facility after colon surgery. Physician report dated 05/11/2024 indicates resident is able to leave the facility unassisted and manages own medications. Facility meal check in paperwork shows the resident did not check in for meals a total of 5 non-consecutive days between 12/01-12/17/ 2024. Based on records reviewed and interviews conducted, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Feb 10, 2025 · control 22-AS-20250107103931

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Administrator Laura Kephart. An initial application to operate a Residential Care Facility for the Elderly was received by CCL on 11/21/2023 for a capacity of 25 ambulatory, 125 non-ambulatory and 40 bedridden residents. Facility appears clean and sanitary and utilizes solar panels. LPA Lyman along with Administrator and Director of Health Services toured the facility at 10:56 AM and observed the following: Structure: Facility is a three story building with an assisted living and a memory care unit. Facility houses a gym, salon, library and activity room. Living Room/ Dining Room: Adequate seating is available in the common areas including multiple seating areas throughout the facility. There are three different dining rooms including a bistro to serve the residents. Bedrooms Residents: Resident rooms are equipped with resident's personal furnishings. Facility will supply furnishings to residents who arrive without personal furnishings. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Residents all have private bathrooms located inside resident rooms. Linens & Hygiene Supplies: Facility has ample bedding and towels for residents in care. Emergency Phone Numbers and Exit Plan: Posted in the entrance of the facility. Food Service: Facility has 2 day perishables as well as 7 day non-perishables. Residents order off a menu with varied choices Smoke Detectors: Smoke detectors/ carbon monoxide detectors were tested operational. Fire extinguishers are mounted and charged. Facility tests carbon monoxide detectors and fire extinguishers in house and contracts with an outside business for sprinklers and smoke detectors. Appliances: Facility appliances as well as laundry are clean and operational. Water Temperature: Tested and recorded between 112.2 and 118.6 degrees F. in tested bathrooms. Emergency Supplies: LPA observed ample emergency food and water as well as a posted emergency disaster plan. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. Medications are stored and locked in the Wellness center. CONTINUED ON LIC 809C DATED 07/19/2024. Facility uses electronic medication administration record. Resident & Staff File: Records are stored secured in the business office. Reading Material, Games, and Equipment: Facility provides activities including exercise, games, happy hour and outings in the community. Outside Areas: LPA observed a clean shaded outside area with a pool secured by a 5 foot fence. Fire Clearance: Approved for 25 ambulatory, 125 non ambulatory and 40 bedridden residents on 02/06/2024. Facility is ready to be licensed. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 19, 2024

Type of visit: Office

COMP II by CAB successfully completed Facility Type: RCFE Application Type: CHOW Capacity: 190 Census (if any clients in care): 126 Method: TEAMS Telephone call with CAB COMP II Participants: Laura Kephart, Administrator, Designee; Denise Munoz, Corporate Director of Adminstration; Shannon Betker, analyst. Applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jun 14, 2024