San Leandro Senior Living

Type of visit: Case Management - Incident

On 4/16/2026 at 11:00 am, Licensing Program Analyst (LPA) Y. Brown conducted an unannounced case management visit regarding two self reported incidents that were reported to CCLD on 4/7/2026 and 4/10/2026. LPA met with Executive Director Glenda Bertucci and explained the purpose of the visit. The first incident report stated that on 3/29/2026 around 9:00 am, Staff two (S2) was preparing resident (R1's) medication when S2 observed that the expiration date on the medication bottle indicated that it expired on 3/5/2026. The incident report indicated that R1 was given expired medication of Amlodipine 2.5 mg from 3/5/2026- 3/29/2026. On 3/29/2026, S2 noticed the expired medication and notified S3 to verify the expired medication and S3 re-confirmed that the medication was expired. R1's order is Amlodipine 2.5 mg: take 1 tablet by mouth 2x daily at 9:00 am. Physician and POA were notified of the incident. R1 was not resulted injury or medical problem due to this incident. In-service training was provided to staff on 3/30/2026. The second incident report stated that on 4/3/2026 around 10:00 am, S1 was reviewing R1's Centrally Stored Medication and Destruction Record and observed that there was a discrepancy with medication dosage of R1's medication of Amlodipine 2.5 mg. S1 observed that R1 was given the Amlodipine 2.5mg but staff only gave R1 1 tablet per day due to the previous physicians order dated on 9/10/2025 that indicated to give R1 Amlodipine 2.5mg 1 tablet by mouth daily. When S1 was reviewing R1's documents S1 realized that the medication dosage was changed to Amlodipine 2.5mg: take 1 tab daily by mouth two times a day on the physicians order dated 12/29/2025 that was received from the Skilled Nursing facility when R1 returned back to the facility. Continued on LIC809C. Continued from LIC809. S1 stated that R1 was given 1 tablet of Amlodipine 2.5 mg daily as opposed to 1 tablet two times a day from 12/29/2025 to 4/3/2026. S1 stated that R1 was sent out to the hospital on 11/21/2026 and was later admitted to a Skilled Nursing Facility from 11/26/2025 - 12/29/2025. S1 stated that the Skilled Nursing Facility changed the dosage amount on 12/8/2026 while R1 was still attending the Skilled Nursing Facility. Physician and POA were notified of the incident. R1 did not result in injury or obtain ill side effects due to this incident. In-service training was provided to staff on 4/3/2026. S1 acknowledged that both the under dosage and the expired medication was overlooked by staff. LPA interviewed S1 and S2. LPA attempted to interview S3. LPA reviewed and obtained R1's MAR (Medication Administration Record) from September 2025 - April 2026, updated Needs and Services Plan, Alert Charting report, Prescriber notification medication error report regarding Wrong Time and Wrong Dose, Physicians Order dated 9/10/2025, and Order Summary Report (Change of dosage) dated 12/29/2025. LPA also reviewed and obtained the Med Tech to Med Tech Communication Log, LIC500 (personnel Report), Resident Roster, and staff training. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalty. Exit interview conducted with Glenda. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 16, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(d) · Plan of correction due date: Apr 17, 2026

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication... assist the resident with self-administration.. This requirement is not met as evidenced by: Based on Interview and record review, the licensee did not comply with the section cited above in administering the incorrect dosage of medication to R1 which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 16, 2026

Plan of correction: The Executive Director(ED) conducted staff training on Wrong Doses and Adverse Reactions on 4/3/2026. ED updated R1's Needs and Services Plan, and created a separate system for when the facility receives physician orders regarding resident medication changes. DEFICIENCY CLEARED DURING VISIT.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(1)(3) · Plan of correction due date: Apr 17, 2026

(h) The following requirements shall apply to medications which are centrally stored (1)Medications shall be centrally stored..(3) Each container shall carry all of the information.. (E) below plus expiration date and number of refills. This requirement is not met as evidenced by: Based on Interview and record review, the licensee did not comply with the section cited above in administering expired medication to R1 which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 16, 2026

Plan of correction: The Executive Director(ED) conducted staff training on Medication Errors and Adverse Reactions on 3/30/2026. ED updated R1's Needs and Services Plan, and utilized a system online called ADL Advantage for Med Tech's to utilize when reviewing medications. DEFICIENCY CLEARED DURING VISIT.

Type of visit: Required - 1 Year

On 1/28/2026 at 1:45 PM, Licensing Program Analysts (LPAs) Y. Brown and P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Administrator (ADM), Glenda Bertucci and explained the purpose of the visit. The facility’s fire clearance was approved for ninety (90) residents, of which forty (40) may be non ambulatory. LPAs toured the facility with the ADM, including but not limited to residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of resident's bathrooms were measured at 120.0 and 113.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Carbon monoxide detector were in operating condition during visit. Fire alarm was last inspected on 07/11/2025. Fire extinguisher all around the facility was last serviced on 4/4/2025. LPAs reviewed six (6) resident and five (5) staff records. LPAs reviewed a sample of resident medication. Continued on LIC809C. Continued from LIC809. The following forms will be updated and submitted to CCLD by 2/4/2026: LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance The following deficiencies was observed: At 2:18 PM, LPAs observed a residents shower with debris and the resident's room with a strong odor of feces. LPAs also observed that the handicapped button in the front door is in disrepair. At 2:36 PM, LPAs observed comet bleach powder and Endust Dust & Clean multi-surface spray in an unlocked cabinet in a residents room. At 4:44 PM, LPAs observed that S1, S3, S4, and S5 files are incomplete Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Administrator Glenda Bertucci gave authorization for Lisa Lostica to sign today's report. Exit interview conducted with Lisa Lostica . A copy of the appeal rights and this report provided.the state’s words, verbatim · CDSS document, Jan 28, 2026

Allegation investigated: Staff did not provide resident with required notice of fee increase

On 9/25/25 at 1:30 p.m., Licensing Program Analyst (LPA) Greg Clark and Ardalan Gharachorloo arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Glenda Bertucci, Executive Director and explained the purpose of the visit. During the course of the investation LPAs interviewed S1 and S2 and reviewed the rate increase letter given to R1. LPAs were unable to interview R1 as she was not in the facility. LPA left his business card for R1 to call or email to discuss the complaint. Review of the letter sent to to R1 revealed the letter meets regulation. This agency has investigated the above complaint. 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. Exit interview conducted, a copy of this report provided. Unfoundedthe state’s words, verbatim · CDSS document, Sep 25, 2025 · control 15-AS-20250918144840

Type of visit: Case Management - Incident

On 3/20/2025 at 4:05PM, Licensing Program Analysts (LPAs) G. Luk and Y. Brown arrived unannounced to conduct a case management visit in regards to an incident report. LPAs met with Executive Director (ED), Glenda Bertucci and explained the purpose of the visit. Based on the incident report, facility have been sending emails and tried to call R1 without response. On 3/10/2025, facility observed R1 was not in his apartment. Facility contacted R1's family and they did not know R1's whereabouts. R1's family informed facility that he will contact the police to file a missing person's report. Police made a visit to the facility to conduct investigation. During visit, LPAs interviewed staff and reviewed R1's file including physician's report, decline services document, and incident report. R1's physician's report stated that R1 can leave the facility unassisted. Interview with staff revealed that family have been providing updates on police investigation. No deficiencies are being cited on this date. LPAs may return on a later date. Exit interview conducted with Glenda Bertucci. A copy of this report provided.the state’s words, verbatim · CDSS document, Mar 20, 2025

Allegation investigated: Staff did not properly care for resident's pressure injury.

On 2/25/2025 at 3:05PM, Licensing Program Analysts (LPAs) G. Luk and P. Manalo arrived unannounced to conduct a complaint investigation and deliver findings regarding the allegation above. LPAs met with Executive Director, Glenda Bertucci and informed her of the reason for the visit. During the course of investigation, LPA G. Luk interviewed 4 residents, 6 staff, witness, and complainant. LPA reviewed and obtained documents including staff list with contact information, admission agreement, care plan, emergency information, care notes, home health information, and discharge documents. Interview with witness revealed that staff used Clorox bleach wipes to clean the area of the pressure injury (buttock area). After reviewing a video of the incident, LPA observed staff grabbed the bleach wipes on the counter to clean R1’s buttock area. (continue on LIC9099C...) Substantiated Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided. Staff left resident in wheelchair for an extended period of time. Interview with staff revealed that R1 can transfer to bed and sometimes need help with transfer. S6 stated that R1 likes being in the wheelchair all the time. Sometimes when S6 put R1 to bed, R1 wants to stay in the wheelchair to watch TV. Staff did not provide resident a clean bed. Interview with witness indicated that R1’s bed is not clean and mattress has urine stain. However, LPA toured a few resident’s rooms and observed the beds are clean. Interview with staff revealed that resident’s beddings would be changed when it’s soiled or wet. Staff did not ensure resident's room was clean and sanitized. Interview with witness indicated that R1’s room was uncleaned and feces were found under the bed. However, LPA toured a few resident’s rooms and observed resident rooms were cleaned. Interview with residents and staff revealed that resident’s rooms are cleaned once a week. Residents stated they did not have any issue of having the room cleaned. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegations are UNSUBSTANTIATED. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Feb 25, 2025 · control 15-AS-20240523150242

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 14, 2025

Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in...competency to meet their needs. This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by staff not properly care for resident's pressure injury which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Feb 25, 2025

Plan of correction: Executive Director (ED) agreed to a written plan to address wound care including staff training and submit a copy to CCLD by POC date.

Type of visit: Required - 1 Year

On 01/07/24 around 10:45 AM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced annual inspection. LPA met with Glenda Bertucci, Executive Director (ED) and explained the purpose of the visit. ED currently holds a standard certificate (#7016878740) exp. 08/13/2026. The facility’s fire clearance was approved for forty (40) non-ambulatory residents. Upon arrival, LPA observed several residents in the main lobby conversing and lounging together. Additional staff and residents were also in the dining area for breakfast. Staff and residents were moving about throughout the facility's common areas as well. LPA toured the facility including, but not limited to the common areas, bathroom, dining area, nurses station, front courtyard, 1st, 2nd and 3rd floors. The facility consists of individual apartments; each floor has an activities area, tabletop games, books, music, and a television on the 1st floor. All outdoor and indoor passageways were free of obstruction. There were no bodies of water present. A comfortable temperature was maintained at the facility. The facility has an emergency food supply on site and contracts with US Foods twice weekly for deliveries. LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. Hot water temperature in the shared bathroom was measured at 109.8 degrees Fahrenheit (F) with hand washing signs, soap, paper towels, and garbage cans; the areas were safe, and sanitary. On site laundry facilities are available. PPE, sanitizer, and paper goods remain sufficient. Safety drill completed 12/18/24, fire extinguisher observed full and last inspected 04/15/24. Continued on LIC809C... ...continued from LIC809. Smoke detectors and carbon monoxide were in operating condition during visit. Emergency Disaster Plan was current. Five (5) staff and seven (7) residents records were reviewed and were complete. The following forms are to be updated and submitted to CCLD: -Resident Roster (Reviewed) -LIC500 Personnel Report (Reviewed) -LIC308 Update Designation of Administrative Responsibility (Reviewed) -LIC610D Emergency Disaster Plan (Reviewed) Exit interview conducted and a copy of this report provided to ED.the state’s words, verbatim · CDSS document, Jan 7, 2025

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff inappropriately locked resident’s room.

On 12/04/2024 at 10:00AM, Licensing Program Analysts (LPAs) Carol Fowler and David Doidge arrived unannounced to open a 10-day initial complaint for the allegation above. Upon arrival, LPA met with Business Office Manager, Lisa Lostica and explained to her the reason for the visit. During the course of the investigation, the Department conducted interviews with residents and staff, and witness. The Department obtained and reviewed the facility & staff roster, R1 Physician report residents assessment, needs and service plan. Allegation: Staff inappropriately locked resident’s room Investigation Finding: Un-substantiated Continue on LIC 9099 C Unsubstantiated Continue from LIC 9099 It was reported to the Department that staff inappropriately locked resident’s room. The department conducted interviews and reviewed documents which reveal that residents apartments are locked and all responsible staff has master keys to get into the apartments for care and emergency services if needed. Therefore, this allegation is un-substantiated. This agency has investigated the complaint alleging Staff inappropriately locked resident’s room. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 4, 2024 · control 15-AS-20241126152636

Type of visit: Case Management - Deficiencies

On 12/4/2024 at 1:15pm, Licensing Program Analysts (LPAs) Carol Fowler and David Doidge arrived unannounced to conduct a complaint investigation visit LPAs observed deficiencies. LPAs met with Lisa Lostica, Business Office Manager and explained the reason for the visit. LPAs observed, R1 Physician Report has not been updated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809 D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights, and this report.the state’s words, verbatim · CDSS document, Dec 4, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Jan 6, 2025

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made...m LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. Based on observation, interview, record review, the licensee did not comply with the section cited above in having current medical assessment for R1 which poses a potential health and safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 4, 2024

Plan of correction: Administrator agreed to get a current medical assessment for R1 and submit documents to CCLD by POC date.

Allegation investigated: Staff did not provide sufficient notice to resident's authorized person of change in use

On 10/28/2024 at 3:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived to deliver amended findings and report for visit conducted on 9/05/24 in regard to the allegation above. LPA met with Glinda Bertucci, Executive Director and explained the purpose of the visit. S1 provided LPA with a copy of a letter dated July 17,2024 that was given to residents and families regarding the facility’s plan to relocate the 3rd floor residents to other floors of the facility and de-license the 3rd floor. LPA reviewed the letter and found that the letter was not in compliance with CCL regulations. The letter did not contain many of the required regulatory components for a notice of eviction. Based on LPA interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted, a copy of this report and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Oct 28, 2024 · control 15-AS-20240826122412

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(5)(A) · Plan of correction due date: Nov 5, 2024

87224 Eviction Procedures (5) Change of use of the facility. (A)The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility. 1. In addition to written notice to quit requirements specified in Section 87224(d),...notice shall include all requirements specified in Section 1569.682(a)(2)(A) through (F) of the HSC. This requirement is not met as evidenced by the 60-day notice letter given to residents was not in compliance with regulation which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 28, 2024

Plan of correction: ADM to submit 60-day eviction letter that meets regulations to LPA, residents, and families by POC date.

Type of visit: Case Management - Deficiencies

On 10/24/24 at approximately 09:35 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger conducted a case management visit pertaining to a letter received by the Oakland CCLD ASC Regional Office from the facility. LPA met with Executive Director (ED), Glenda Bertucci and explained the purpose of the visit. On July 11, 2024, the Oakland CCLD ASC Regional Office received from the facility a letter of intent to de-license the third floor of the physical plant and convert those units for Independent Individuals who are 55 years of age and older. The letter did not specifically request approval from CCLD and had insufficient detail pertaining to how the co-mingling of Independent aged 55+ renters, and licensed RCFE Assisted Living residents, would be managed to ensure the Health & Safety of the Assisted Living residents. On 10/16/24 LPM Jeremy Fong and on 10/24/24 LPA J. Clancy-Czuleger and ED confirmed that the facility’s website is advertising for independent renters aged 55 and older, which constitutes a change to the Plan of Operation without having obtained approval from Community Care Licensing. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 24, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208 · Plan of correction due date: Nov 7, 2024

“…Any significant changes in the plan of operation…shall be submitted to the licensing agency for approval." This requirement is not met as evidenced by: Based on observations, interviews and record review, the licensee did not comply with the section cited above in by changing the plan of operation without CCLD approval which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: By POC date, the facility will submit to CCLD for review a new, detailed plan of operation describing the changes that the Licensee wishes to implement. The facility also agree to not admit any more resident to the 55+ floor until they have received approval of their new plan of operations

Allegation investigated: Staff did not assist resident in feeding. Resident developed pressure injury while in care.

On 9/18/2024 at 9:40AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and to deliver complaint findings for the allegations above. LPA met with Executive Director, Glenda Bertucci and explained the purpose of the visit. During the investigation, LPA interviewed 4 residents, 5 staff, and complainants. LPA reviewed and obtained documents including staff list with contact information, LIC500, physician's report, preplacement appraisal, care plan, emergency information, care notes, hospice information, outside agency documentation, meal tracker, and discharge documents. Staff did not assist resident in feeding. R1's physician's report dated 7/31/2023 indicated that R1 is unable to feed self. However, R1's assessments dated 1/25/2023 and 8/26/2023 revealed that care for meals was independent. Interview with staff revealed that R1 can feed independently. (Continue on LIC9099C...) Unsubstantiated Resident developed pressure injury while in care. R1's physician's report dated 7/31/2023 revealed that R1 has a history of skin condition or breakdown. R1 has home health that would assist with R1's wound care. Outside agency documentation indicated that a nurse have provided wound care for R1. Interview with staff revealed that R1 was repositioned every 1-2 hours. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegations are UNSUBSTANTIATED. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Sep 18, 2024 · control 15-AS-20230822145539

Allegation investigated: Staff did not ensure that resident took medication as prescribed

On 9/05/24 at 10:30 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegation above. LPA met with Glinda Bertucci, Executive Director (ADM) and explained the purpose of the visit. During the course of the investigation LPA interviewed the Reporting Party (RP), S1 and S2. Allegation: Staff did not ensure that resident took medication as prescribed LPA interviewed S2 who stated that she was made aware of an issue regarding R3’s medications. When facility staff were moving R3’s bed, due to R3 being relocation to another floor of the facility, facility staff noticed several pills under R3’s bed. This was brought to the attention of S1. It was determined that R3 must have been “cheek-ing” her medications and throwing them under her bed after the staff left her room. R3 is under the facility’s medication management program. ***report continues on LIC9099C*** Substantiated ***report continues from LIC9099*** Based on LPA’s observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.CCLD1515the state’s words, verbatim · CDSS document, Sep 5, 2024 · control 15-AS-20240826122412

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 5, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. Based on interviews conducted the licensee did not comply with the section cited above. Medications were found under R3's bed which poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 5, 2024

Plan of correction: Administrator to conduct a medication training adressing the issue of residents cheek-ing medication and provide proof to LPA by POC date.

Allegation investigated: Staff did not keep the resident's room clean or sanitary

On 9/05/24 at 10:30 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation in regard to the allegations above. LPA met with Glinda Bertucci, Executive Director (ADM) and explained the purpose of the visit. During the course of the investigation LPA interviewed the Reporting Party (RP) and S1. LPA toured the facility including the apartments of R1, R2 and R3 and reviewed documents with the ADM. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** Allegation: Staff did not keep the resident's room clean or sanitary. LPA toured the apartments of R1, R2 and R3. LPA observed all three apartments to be clean and odor free. LPA also observed a notice in each apartment of their weekly housekeeping cleaning schedule. R3 stated that she loves her housekeeper and that she does a “wonderful job.” This agency has investigated the complaint alleging staff did not keep the resident's room clean or sanitary. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 5, 2024 · control 15-AS-20240826122412

Type of visit: Case Management - Incident

On this day at around 2:20 PM, Licensing Program Analyst (LPA) Luisa Fontanilla arrived at the facility to conduct a case management visit related to an incident reported by the facility. LPA met with Gendelle Camarillo, Resident Services Director. Executive Director (ED) Glenda Bertucci arrived at around 3pm. . On July 14, 2024, a stranger came to the facility and dropped off R1. R1 was found at the Safeway Supermarket on Washington Ave. which is 0.3 miles from the facility. R1's Physician's Report indicates R1 has Mild Cognitive Impairment (MCI) and is not able to leave the facility unattended. Based on interview with RSD, R1 was not harmed from the incident. RSD added that staff training was conducted and R1 has been reassessed by R1's doctor. Pending the release of R1's updated Physician's Report, the facility has plans in place to ensure R1's safety while at the facility. If R1 is diagnosed with Dementia, R1 will need to be moved out of the facility because the facility does not have a dementia program. A technical violation advisory was issued during the visit. A copy of this report was provided to the Executive Director.the state’s words, verbatim · CDSS document, Jul 30, 2024

Type of visit: Case Management - Deficiencies

On 5/29/2024 at 2:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Interim Executive Director, Jeralyn May and explained the purpose for the visit. While LPA G. Luk was at the facility for a complaint investigation (#15-AS-20240523150242), the following deficiency was observed. After reviewing Guardian system, LPA G. Luk observed staff (S1) was fingerprint cleared, but not associated to the facility. Facility contacted RO (Regional Office) and associated S1 to the facility during visit. LPA re-checked Guardian system and observed S1 has been associated to the facility as of today, 5/29/2024. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, May 29, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87355(e)(2) · Plan of correction due date: May 30, 2024

Criminal Record Clearance. All individuals subject to a criminal record review ...Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not associating S1 to the facility which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, May 29, 2024

Plan of correction: Facility associated S1 during inspection. Deficiency cleared.

Allegation investigated: Licensee is not assuring the provision of laundry services for residents' clothing without additional cost.

At 11:30 a.m., on this day, March 20, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with interim Administrator Jerayn May and Senior Business Office Manager Lisa Lostica, and informed the reason for visit. During investigation. LPA obtaineed copies of resident roster, LIC500 Personnel Report. From the resident roster, LPA selected 3 residents for file review and obtained copies of Admission Agreement, Resident Services Plan, Care and Services Plan and record of service for personal laundry. LPA also obtained copy of notification dated December 20, 2023 pertaining to laundry service fee for personal laundry, and conducted interviews. .........continued on 9099C Substantiated Jeralyn May stated that a fee for residents' personal laundry is being charge effective March 1, 2024, and the 60-day notification was provided to all resident which was confirmed with copy of the notification obtained by LPA. Copies of records for personal laundry with corresponding charges were obtained by LPA on this same day. Staff (S1, S2 and S3) stated residents are started to be charge for laundry of clothing starting March 2024. Two of the 3 residents interviewed stated they were not charge before and confirmed they are being charge for laundry of their clothing effective March 2024. Based on LPA review of records and interviews, the preponderance standard has been met, therefore the allegation of "Licensee is not assuring the provision of laundry services for residents' clothing without additional cost" is substantiated. Deficiency is cited per Title 22 California Code of Regulations, and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the Jeralyn May. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 15-AS-20240311152642

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(30)(F) · Plan of correction due date: Apr 3, 2024

87307 Personal Accommodations and Services: (a).....The following provisions shall apply: (3).....if the resident is unable or chooses not to provide them, the licensee shall assure provision of:(F) Basic laundry service (washing, drying, and ironing of personal clothing). -This requirement is not met as evidenced by: -Based on records review and interviews, the licensee did not comply with the section above for charging the residents for laundry of personal clothing which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: Administrator to do the following, and submit proof by 4/03/24: 1. Stop charging the residents for personal laundry. 2. Notify the residents regarding item # 1. 3. Revise the Admission Agreement pertaining to laundry service.

Type of visit: Case Management - Deficiencies

While at the facility investigating a complaint (Control # 15-AS-20240311152642), Licensing Program Analyst (LPA) Delmundo observed the laundry room where laundry supplies are kept was unlocked. LPA informed staff, Gendelle Nebril Camarillo who was on the floor at the time. LPA also informed Lisa Lostica. Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the Jeralyn May. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 20, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Mar 21, 2024

87309 (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for unlocked laundry room which posed an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: Staff locked the room. In addition, administrator to in-service the staff and submit proof by 3/21/24.

Type of visit: Required - 1 Year

On 01/31/24 at 08:55 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with Adiam Welday, Executive Director and explained the purpose of the visit. LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the facility including but not limited to 6 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway was maintained at a comfortable temperature. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. At 10:02 am LPA reviewed 5 residents records. At 11:45 am, LPA reviewed 5 staff records and 4 of 5 were fingerprint cleared and associated to the facility. The following deficiency was observed during the visit: One staff was not fingerprinted A $500.00 civil penalty is assessed. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty. The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 31, 2024

Type of visit: Case Management - Other

On 01/18/2024 at 12:00pm Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a case management visit to follow-up on a death report received by Community Care Licensing that was faxed on 11/10/2023. LPA met with Executive Director, Adiam Welday and explained the purpose of the visit. R1 passed away on 11/02/2023 with an unknown cause of death. Administrator stated that R1 had episodes of collapsing while R1 was with the family. R1 stated that the family is the one that reported the collapsing per the Death Report. Administrator stated that no one at the facility witnessed the collapsing. During today's visit LPA obtained additional information pertaining to R1's death: Physician's Report Resident Assessment Face Sheet Assessment for Medication Self-Management Needs and Services Plan Internal Incident Report LIC809 Continued.... LIC809-C Continued... LPA requested from facility a copy of R1's death certificate. LPA was informed by Administrator that they phoned the family and left a message requesting the death certificate. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Jan 18, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Jan 25, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency....(1) A written report shall be submitted to the licensing agency ... within seven days of the occurrence of any of the events......(A) Death of any resident from any cause regardless of where death occured This requirement is not met evidenced by: Based on record review, the Administrator did not comply with the section above for not submitting the death report within 7 days which posed potential personal rights risk to person in care.the state’s words, verbatim · CDSS document, Jan 18, 2024

Plan of correction: Administrator will go over reporting requirements and submit a self certification of understanding of reporting requirements. Administrator shall submit self-certification to CCLD by POC due date.

Allegation investigated: Refused to allow resident to come back to the facility

On 10/20/2023 at 1:50PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with Maria Locstica, Business Office Manager. During the initial 10-day complaint visit. LPA interviewed staff, collected the following documents: Resident Roster, Personnel Report, Pacifica Policy, Clinical Summary for R1, Corespondence with staff medical team, S1stated that R1left the facility to go to the hospital after having pain on her ankle. The hospital discharged R1 to a Skilled Nursing Facility (SNF) for infection in her wound. The facility was informed by R1s daughter that they could no longer stay at the SNF for insurance reasons and they were looking to come back to the facility. The facility staff looked into the kind of wound R1 had and what stage it was at. They were informed that it was not stageable. Continued on 9099C... Unsubstantiated ...Continued from 9099 The facility informed R1 and family that they are not a medical facility and are unable to care for the wounds of this seriousness. The facility said that they could wait for the wound to heal for R1 return or to obtain hospice services to care for the wound. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 20, 2023 · control 15-AS-20231013125437