Santa Barbara Memory Care

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management visit to address deficiencies noted during Complaint Control #29-AS-20260910155554. The Case Management visit is being conducted to address CCLD’s concerns that were observed during the course of the investigation. Kathy Martin, Long Term Care Ombudsman Representative participated in the visit. LPA Kontilis and LTCO Martin met with Administrator Lisa Gerr and explained the purpose of the visit. Entrance Interview Conducted: During the complaint investigation, LTCO and LPA observed the exterior doorway leading out to Resident 1’s (R1’s) room was blocked with a recliner, a table with approximately 6 stuffed animals and a decorative picture, and a portable air conditioning unit were blocking the doorway. During the complaint investigation, LTCO and LPA observed the hallway located on the east side of the building had foul odors indicative of urine lingering throughout the hallway. Additionally, LTCO and LPA observed a soiled and moist couch in Resident 2’s (R2’s) room. During the complaint investigation, LTCO and LPA observed a note posted stating “Shower Out of Service 9/4/2026” on the door entering the shower on the south hallway. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.the state’s words, verbatim · CDSS document, Sep 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Sep 17, 2026

87202(a) Fire Clearance: All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by: Based on observation and interviews conducted, the Licensee did not comply with the section cited above as the exterior door leading out of R1’s room was blocked with several items which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Administrator agrees to keep all items removed from blocking the exterior door. Items removed at the time of the visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87625(b)(3) · Plan of correction due date: Sep 21, 2026

87625(b)(3) Managed Incontinence: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on observations conducted the Licensee did not comply with the section cited above as lingering foul odors were observed near R2’s room; a seat cover in R2’s room was soiled and moist with foul odors which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Administrator agrees to ensure hallway and residents' rooms are kept clean and free of foul odors. Administrator agrees to submit written understanding of CCR87625(b)(3). Written acknowledgment will be submitted directly to LPA via email.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 21, 2026

87303(a): Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on interviews conducted, the Licensee did not comply with the section cited above as a shower was observed to have a sign posted “Out of Service 9/4/2026” which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Administrator agrees to submit written statement acknowledging CCR 87303 in its entirety. Administrator agrees to be prompt in maintenance and repairs. Administrator agrees to submit written acknowledgement per 87303 in its entirety. Written acknowledgement will be submitted to LPA via email.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Case Management – Other visit. LPA was greeted by Administrator Lisa Gerr and explained the for the purpose of the visit. Entrance interview conducted. The purpose of today’s visit is to make an observation pertaining to the facility’s adherence to the fire clearance regulation. Upon arrival, LPA observed a chained bike lock wrapped around the pedestrian gate at the entrance into the memory care yard. Administrator stated she learned the pedestrian gate has been inoperable since 7/7/2026. Administrator stated she had been notified that the gate was malfunctioning prior to 7/7/2026 to which she tested the gate on 7/7/2026 then requested a service call from a local repair company. On 7/21/2026, a representative from the repair company came to repair the gate. Administrator stated the service representative diagnosed the repair was a result of debris build-up, cleaned the lock, and checked it for operability. Administrator stated that immediately following the service repair, Staff 1 (S1) tested the gate and noticed that it was again not operable. Administrator stated a request has been made for the gate lock to be replaced but a date has not yet been provided. During today’s visit, LPA observed the bike lock wrapped twice around the pedestrian gate, the vehicle gate is operable, and pedestrians as well as vehicles are accessing the vehicle gate for entrance and exit. At approximately 10:29 am, LPA and Administrator observed a service provider access the vehicle gate, Please continue to 809-C, Pg 2. observed the vehicle gate opened to its full extent, and the service provider entered through the vehicle gate and the gate closed after 90 seconds. At approximately 10:41 am, LPA and Administrator observed a visitor enter through the vehicle gate, the vehicle gate again opened to its full extent, and the visitor entered through the vehicle gate and the gate closed after 77 seconds. At approximately 10:46 am, LPA and Administrator observed a vehicle leaving the facility through the vehicle gate at which time the vehicle gate opened to its full extent, the vehicle left the premises and the vehicle gate closed after 111 seconds. Administrator stated she is aware of the safety risk for residents when the vehicle gate is open. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted. Copy of report and Appeal Rights issued at the time of the visit.the state’s words, verbatim · CDSS document, Jul 22, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jul 23, 2026

87303 Maintenance and Operation: (a) The facility shall be...safe...and in good repair at all times. This requirement is not met as evidenced by: The licensee did not comply with the section cited above when observation revealed the pedestrian gate entering/exiting the facility is inoperable with access limited to the vehicle gate which remains open for an extended amount of time which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 22, 2026

Plan of correction: Administrator agrees to provide written plan in place to notify all responsible parties, guests, and/or visitors of the inoperable pedestrian gate. Administrator agrees to post signage throughout the facility to inform responsible parties, guests, and visitors to be aware of the inoperable pedestrian gate. Administrator agrees to notify all staff to take additional cautionary measures to ensure safety of residents, responsible parties, visitors, and staff.

Allegation investigated: Licensee did not protect resident from being inappropriately touched by another resident. Staff does not provide a safe environment for resident.

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced subsequent complaint visit to deliver final findings for the above-stated allegations. During today’s visit, LPA met with Administrator Lisa Gerr and explained the purpose of the visit. LPA Kontilis conducted the initial visit on 3/19/2025 from approximately 12:15 pm to 3:45 pm at which time LPA conducted interviews and obtained documents pertaining to the investigation. On 4/16/2025 from approximately 11:00 am to 2:00 pm, LPA conducted a subsequent visit and a Case Management visit to the facility at which time LPA obtained documents and conducted interviews. On the allegation, Staff did not protect resident from being inappropriately touched by another resident: Reporting Party voiced concern for residents’ safety when a resident was found in another resident’s room touching the other resident’s briefs and when the resident was re-directed out of that resident’s room, the resident stated they were directed to do so by another individual; however the resident was unable to identify the other individual. Records reviewed and interviews conducted revealed R1 has a diagnosis of neuropathy Please continue to 9099-C, Pg 2 Substantiated and no diagnosis of dementia or mild cognitive impairment. All other residents in the facility have dementia or mild cognitive impairment. Interviews conducted revealed staff observed Resident 1 (R1) demonstrate inappropriate behavior towards other residents. Staff stated R1 was observed trying to go into other residents’ rooms and described R1’s behavior as “predatory”. Interviews conducted revealed R1 was observed with their hand between Resident 2’s (R2’s) legs and R1 “backed off” when R2 became combative towards R1. Interviews conducted revealed R1 was found “multiple times” with their hand on Resident 3’s (R3’s) breasts. Interviews conducted revealed Resident 4 (R4) demonstrated a different demeanor in R1’s presence and appeared to be “uncomfortable” when R1 was near R4. Interviews conducted revealed staff reported R1’s behavior and specific incidents to Administrator Gerr. Administrator responded saying the interactions are most likely consensual, especially between R1 and R4, and noted residents have personal rights. Staff stated they felt R1 followed and pursued R4, and coerced R4. The investigation revealed Administrator did not provide support or guidance to the staff and instead deflected the incidents by saying R1 had “their needs”. Staff indicated they were never directed to provide additional supervision to R1 or R4, despite the Administrator being aware of R1’s behaviors. Additionally, text messages and interviews revealed staff found R4 in R5’s room, with R4’s pants pulled down and the covers off of R5. Interviews revealed R4 was touching R5’s briefs. R5 was saying they did not need assistance, believing R4 to be a staff. R4 was very confused when staff intervened. Based on interviews conducted and records reviewed, the allegation Staff did not protect resident from being inappropriately touched by another resident is deemed Substantiated at this time. On the allegation, Staff does not provide a safe environment for resident: Reporting Party voiced concern for a resident’s safety when staff reported to Administrator that R1 was demonstrating inappropriate behavior towards other residents. Interviews conducted revealed R1 was observed trying to enter other residents’ rooms and when R1 was “called out” on their behavior, R1 would “slink off” and go to their room. Interviews conducted revealed when R1 “was affectionate” towards residents in the dining room, and when R1 was told “No” by staff, R1 would then leave the area and go to their room. Records review and interviews conducted revealed R1 has a diagnosis of neuropathy and no diagnosis of dementia or mild cognitive impairment. All other residents in the facility have dementia or mild cognitive impairment. By R1 residing in the facility, R1 is in an environment that is not compatible with their mental cognition and diagnosis. On 4/16/2025, LPA Kontilis conducted a Case Management visit to the facility wherein a citation was issued against the facility as a violation for admitting a resident who did not have a dementia diagnosis and did not require the level of care provided by the facility. The facility is a secured Please continue to 9099-C, Pg 3. perimeter memory care facility, per regulation, all residents must have conservatorship to be in a secured perimeter memory care facility or a signed acknowledgment that they agree to be in a secured perimeter facility. Based on the information obtained over the course of the investigation, R1 residing in a locked memory care facility with no dementia or mild cognitive impairment diagnosis and is/was residing in a facility that is not compatible with other residents in care, presents an unsafe and vulnerable environment detrimental to all residents including R1. Therefore, the allegation that Staff does not provide a safe environment for a resident is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Copy of report issued. Appeal Rights issued.the state’s words, verbatim · CDSS document, Apr 7, 2026 · control 29-AS-20250310083615

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 9, 2026

87468.2(a)(4) Personal Rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the licensee did not comply with the section cited above when administrator did not protect a safe environment for residents in care resulting in resident(s) being inappropriately touched by another resident which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 7, 2026

Plan of correction: Administrator agrees to review personal rights with all staff to include properly managing relationships between residents. Written documentation of training will be submitted directly to LPA via email including description of training, first and last names of trainees, dates and duration of training and name of trainer. Administrator agrees to send training documentation directly to LPA via email no later than POC due date (4/9/2026).

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management visit to address deficiencies noted during the course of the investigation for Complaint Control #29-AS-20250310083615. LPA Kontilis met with Administrator Lisa Gerr and explained the purpose of the visit. During today’s visit, LPA addressed concerns that Administrator accepted Resident 1 (R1), a non-conserved individual who resided in the facility from 7/8/2024 to 4/27/2025. Records review and interviews conducted revealed R1 had a diagnosis of neuropathy and no diagnosis of dementia or mild cognitive impairment. Interviews conducted and records reviewed revealed R1 was not allowed visitors while residing in the facility and a sign was posted in the medication room by Administrator Gerr specifically naming R1’s family member with whom R1 co-habited prior to R1’s admission into the facility was not allowed to visit. Interviews conducted and records reviewed further revealed R1 was restricted to the confines of the locked facility and was not allowed to leave the facility upon their choice with or without R1’s family member. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Copy of report issued. Appeal Rights issued.the state’s words, verbatim · CDSS document, Apr 7, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Apr 9, 2026

87468.1(a)(11) Residents...shall have all of the...personal rights: (11) To have their visitors...and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement is not met as evidenced by: Based on observation and interviews conducted, the licensee did not comply with the section cited above when R1 was not allowed visitors which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 7, 2026

Plan of correction: Administrator agrees to provide written documentation acknowledging residents rights to have visitors. Administrator agrees to submit written acknowledgement to LPA via email no later than POC due date (4/9/2026).

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1(a)(6) · Plan of correction due date: Apr 9, 2026

87468.1(a)(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement is not met as evidenced by: Based on observation and interviews conducted, the licensee did not comply with the section cited above when R1 was not allowed to leave or depart the facility upon their choice which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 7, 2026

Plan of correction: Administrator agrees to provide written documentation acknowledging residents rights to leave the facility with family and friends. Administrator agrees to submit written acknowledgement to LPA via email no later than POC due date (4/9/2026).

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Required Inspection of the facility. At the time of arrival, there were sixteen (16) residents in care and two staff on duty. Lisa Gerr, Administrator arrived at approximately 10:38 am. LPA explained the purpose of the visit. Entrance interview conducted: The facility is a one-story Residential Care Facility for the Elderly (RCFE) with a capacity of thirty-six (36) residents. The facility is a memory care facility for residents with a dementia diagnosis. The facility has a fire clearance for thirty-six (36) non-ambulatory residents of which thirty-six (36) can be bedridden and has a hospice waiver for ten (10) residents. Currently, there are two (2) residents on hospice and 2 bedridden residents residing in the facility. Administrator and LPA toured the facility to assess the physical environment and accommodations. The following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. Upon entry, there is a gate that requires a code to enter the premises and a phone number posted to the facility for those who do not have a code. Entering through the gate, is a large walkway and driveway leading up to a large front patio with seating areas including patio chairs, tables with umbrellas, couches, and mini-couches. Entering past the patio area, the administrator’s office is located on the west side of the building. Staff files and other confidential information are kept in the medication room located directly inside the front entrance to the right of the area. Entering into the main area of the facility is the dining area/common area on the east side of the building. Socializing, meals, and activities are held in the dining/common area. Please continue to 809-C, Pg 2. The kitchen is located at the back of the dining/common area and is inaccessible to residents in care. LPA observed seven (7) days of non-perishable food items and two (2) days of perishable food items. LPA reviewed personnel records. All staff have had a criminal background clearance and are properly associated to the facility. Due to time restraints, LPA will return at a later date to continue the annual inspection. Exit interview conducted. No deficiencies noted. Due to technical difficulties, copy of report issued via email.the state’s words, verbatim · CDSS document, Feb 25, 2026

Allegation investigated: Due to lack of supervision, resident came in resident's room and "pooped" on resident's belongings. Due to lack of supervision, resident physically assaulted resident.

On 01/15/2026, Licensing Program Analyst (LPA) Jeffries conducted a subsequent complaint visit to issue final findings on the allegations above. LPA met with Administrator, Lisa Gerr, explained the purpose of the visit. On 5/2/2025 from 11:40am to 3:00pm, LPA Kontilis conducted an initial complaint visit to obtain documents and interview staff and administrator. LPA conducted interviews with R1 on 5/28/2025 at 11:05am and 5/30/2025 at 11:13am. LPA Jeffries interviewed administrator on 01/15/2026 at 1:00pm. On the allegation: Due to lack of supervision, resident came in resident's room and "pooped" on resident's belongings. It was alleged in March 2025, a resident came into Resident 1 (R1)’s room and “pooped” on R1’s belongings. R1 stated they were moving to a different room in the facility and smelled something. R1 stated they went closer to a box that had their items packed in it, and it smelled bad like feces. R1 stated the Administrator was in denial at first but many people knew what happened so they could not deny it anymore. R1 stated staff had gloves on and were taking the box out. CONTINUED on LIC9099-C Substantiated R1 stated the Administrator was in denial at first but many people knew what happened so they could not deny it anymore. R1 stated staff had gloves on and were taking the box out. LPA reviewed text messages between the Administrator and RP discussing the incident. The messages show RP stating they think the resident who pooped in the box may be the same one that came into R1’s room at night. LPA reviewed message from Administrator, that discusses the resident R1 was concerned about “who had been coming into [R1’s] room.” The message states the resident’s doctor has been contacted and they do not expect any more issues, and in the meantime staff will keep a close eye on the resident. On 01/15/2026 LPA Jeffries conducted an interview with Administrator who stated,On 01/15/2026 LPA Jeffries conducted an interview with Administrator, Lisa Gerr, who stated R2 did have observed elevated behaviors and were addressed by physician days after two incidents pertaining to this complaint. LPA Jeffries noted on prior visit to the facility on 05/21/2026 that facility was short on staff and was addressed in a case management visit report on 05/21/2026. Based on the information obtained, the allegation is Substantiated at this time. On the allegation: Due to lack of supervision, resident physically assaulted resident. It was alleged a resident came into R1’s room at night, ripped the blankets off R1 and grabbed R1’s arms. Staff interviewed stated there was an incident one night where Resident 2 (R2) wandered into R1’s room. Administrator stated R2 had experienced a change in demeanor, with wandering, going into other resident’s rooms, moving a shirt from room to room. Administrator stated they had informed R2’s physician and responsible parties, and watched R2 more closely with hourly checks. Administrator stated R2 had become more aggressive to R1. Administrator stated R1’s RP informed them a resident came into the room and “attacked” R1. Administrator stated they were no injuries, and they gave R1 a lock for their door. Administrator stated the same evening R2 gave unwanted advanced to a visitor, and the Administrator tried to redirect them, but R2 gave them an angry look. Administrator stated they had another appointment scheduled with R2’s physician on 5/6/2025 due to the increased behaviors. Administrator stated they offered R1 anything they needed to feel safe aside from the lock on the door. When interviewed, R1 stated a resident was ripping blankets out of their hand, and was grabbing them. R1 confirmed the Administrator got them a key for their door, but someone could come through the bathroom. R1 stated they were told R2 also went into another resident’s room and was standing over their bed staring at them. LPA reviewed text messages between the Administrator and RP discussing the incident. The messages show RP stating they think the resident who pooped in the box may be the same one that came into R1’s room at night. LPA reviewed message from Administrator, that discusses the resident R1 was concerned about “who had been coming into [R1’s] room.” The message states the resident’s doctor has been contacted and they do not expect any more issues, and in the meantime staff will keep a close eye on the resident. Based on the information obtained, the allegation is Substantiated at this time. The Administrator gave their next available time at the facility. During interviews, R1 indicated they believed the Administrator was “brainwashing” them to turn against their RP. R1 also stated they had panic attacks. R1 stated they had just had a medical treatment that takes a toll on them, and then Administrator explained aspects of the lease or admission agreement. When R1 put on glasses and read the documents, they were different and they felt the Administrator had “lied.” R1 stated the Administrator made them upset and they ended up in the hospital with atrial fibrillation. R1 was unable to be interviewed any further. RP stated although R1 did not have dementia, they felt R1’s medical treatments were affecting some parts of R1’s memory. Staff interviewed confirmed R1 had memory issues, and in the staff’s opinion, was confused, very anxious, could get “rattled.” 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 at this time. The Administrator is reminded to conduct themselves in an appropriate manner at all times that ensures residents are treated with respect. Exit interview conducted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 29-AS-20250501113652

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jan 29, 2026

87468.2(a)(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above when staff provided inadequate supervision to R2, which posed a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: Adminsitrator, in the month of May 2025 incresed staffing in facility. Additional position was added in June 2025, to address resident supervisional needs. Administrator emalied staff io LPA.

Allegation investigated: Facility did not issue a refund to resident.

At 3:30pm on 08/27/2025, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to deliver the final findings to this complaint. LPA met with, Wellness Director, Cielo Valladares, announced who he is and the reason for the visit. LPA received verbal authorization from Administrator via telephone call to have Wellness Director, Cielo Valladares review and sign complaint findings report. As to the allegation, “Facility did not issue a refund to resident.” It was alleged that, “the facility was taking about three weeks to cash the resident's checks and then were placing late fees…” the facility was processing checks late when recived on time, when they were mailed and followed up with phone call confirmation. It was discovered through interviews and documentation that on 05/15/2025, Licensing Program Analyst (LPA) Jeffries conducted an interview with Family Member 1 (F1) who stated that they had sent a check for Resident 1 (R1) every month from out of state prior to the billing date on the 1st of the month. F1 stated that they followed up to the facility with a confirmation phone call to ensure that the facility received the check. F1 stated that, “Many of the issues we experienced were due to frequent changes to the administrative staff. CONTINUED on LIC9099-C Substantiated Communication was poor at best.” On 06/25/2025 LPA reviewed documentation provided by F1 that included a single email correspondence by email dated Tuesday January 30th, 2024 @ 8:00pm with Business Office Manager of Facility, Staff 1 (S1), acknowledging there was need to solve “billing issues”. LPA also reviewed documentation of billing statements for the 30 months that R1 resided in the facility. LPA noted that late fees of $100 and $250 began to appear on R1’s billing statement on 04/15/2022 which showed 8 late charges of $100 and starting 06/15/2025 there were 14 late charges of $250 beginning on 06/15/2023. Two of those late charges of $250 were refunded, the first refund was 07/15/2025, and the second was 08/15/2025, both charges were refunded the same day they were billed according to F1’s billing statement. In February of 2024, F1’s bank statement indicated alternative payment method to Rent Café’, From February 2024 through July 2024 all payments were assessed a late fee of $250. Based on the email dated 01/30/2024. Late charge totals from 04/15/2022 through 05/15/2023 of $100 totaled $800 in accessed late fees. From 06/15/2023 through 07/13/2024 there were 14 late fee charges of $250, with 2 late fee charges of $250 refunded ($500) accounting for a total of $3000 ($3500) in accessed late fees at $250. For the 30 months R1 resided in the facility there was a total late fee charge of $3800 ($4300) noted to R1’s billing statement. The email from S1 to F1 dated 01/30/2025 indicates there are billing issues accounts for a total of $2300 in late fee charges up to that date. LPA noted that facility Contact pertaining to payments reads as follows, “The Monthly Fee is payable in advance by the first (1st) day of each calendar month and is considered delinquent of not received by the fifth (5th) day of the month."Based on check book log provided by F1 which shows dates posted on checks are prior to due date and interview indicating checks were place in the mail before due date and followed up with phone calls for confirmation that checks sent by mail had been received, with no facility staff currently employed that handled mail payments available to support to the contrary. On 02/24/2025, and 05/21/2025 LPA interviewed current facility Administrator Lisa Gerr, who stated they did not have knowledge of specific billing issues prior to being an administrator. LPA reviewed billing documentation of 16 additional residents all residing at the facility during the same time period. All 16 residents resided approximately one month or less compared to R1’s 30 months as a resident, with 3 out of 16 receiving late fee charges with less than one month of being a resident at this facility. LPA attempted to contact former Business Office Manager (S1) who sent the “resolve billing issues” email but received no response. LPA noted that R1’s billing statement indicated a refund of $756.46 which notes there is a potential overbilling discrepancy of $3,043.54. At this time based on documentation and interviews, there is enough evidence support the allegation of, “Facility did not issue a refund to resident.” and is substantiated at this time. Exit interview, report read, citation issued, appeal rights and report provided.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 29-AS-20250219113025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(3)(B)2 · Plan of correction due date: Sep 10, 2025

87507 Admission Agreement (g) Admission agreements shall specify the following: (3) Payment provisions, including the following:(B) Rate for additional items and services, including: 2.A separate charge for an item or service may be assessed only if that charge is included in and authorized by the admission agreement. By not processing checks revived in the mail when in timely manor when revived, which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Administrator agrees to create a Mail intake log to identify dates mail is received. Administrator will write a policy on mail intake and email supervising LPA with policy by 09/10/2025. Administrator will contact Business office for agreement to satisfy outstanding fees balance before 09/10/25.

Allegation investigated: Staff are mismanaging residents medication.

At 11:30am on 06/25/25, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the initial investigation to the allegation to this complaint. LPA met with,Adminsitrator, Lisa Gerr, announced who he is and the reason for the visit. LPA conducted interviews, requested and reviewed documentation. Based on documentation and interviews, LPA was able to make a determination a final finding on the allegation to this complaint as follows: As to the allegation of, "Staff are mismanaging residents medications." It was alleged that, Resident 1 (R1) was hospitalized on 05/01/25 and subsequently did not return as a resident to this facility on that day. The evening of 05/01/25, R1's medications were provided to Witness 1 (W1), R1's responsible party, with the medication Olanzapine 2.5mg missing, according to W1. It was discovered through interview on 06/23/2025, LPA Jeffries interviewed W1 who stated, "the facility Administrator (Lisa Gerr) brought the medications to me (W1), and after looking through the medications, I (W1) observed that some medications were missing, especially...(R1) chemo medication (Olanzapine 2.5mg)." CONTINUED on LIC9099- C Substantiated W1 stated that they contacted Administrator Lisa Gerr who stated that the medication Olanzapine was not delivered to her facility until after R1's discharge on 05/01/25. W1 stated that they have receipt from Federal Drug Company that shows all medications were delivered to the facility on 04/22/25. W1 stated that the missing medication was eventually provided to R1's new facility Administrator on 05/19/2025. On 06/25/25 LPA Jeffries conducted an interview with Administrator Lisa Gerr, who stated, "..on (05/01/2025) R1 returned to the facility after normal business hours requesting all medications for 1 week. Administrator provided all medications from R1's medication storage bin with custody receipt provided and singed. Administrator stated that medication in question was placed in S1 desk drawer and was discovered at unknown later date and was delivered to new facility with custody receipt 05/19/25.On 06/24/25, LPA reviewed documentation from Federal Drug Company, Drug Order Delivery Form, which indicated that a total of 6 medications, including (Olanzapine 2.5mg, Quantity 30) were delivered to this facility on 04/22/25, singed and dated by facility Staff 1 (S1). This delivery form establishes the custody of R1's medications were in the care of this facility starting on 04/22/25. On 05/01/25 all other medications, with the exception of Olanzapine 2.5mg, were provided to W1 by the Administrator, Lisa Gerr, due to R1 permenatly leaving as a resident on the evening of 05/01/25. On 06/25/25, LPA Jeffries received an email from Robert Glock, Administrator of Rt 1's current facility stating that on 05/19/25 Lisa Gerr dropped of R1's personal items that included the Olanzapine 2.5mg medication. Due to the facility having documented custody of the Olanzapine medication on 04/22/25, and on 05/01/25 Administrator, Lisa Gerr provided W1 with R1s medications, excluding the Olanzapine, Based on documentation, and interviews, there is enough evidence to support the allegation of, "Staff are mismanaging residents medications." and is substantiated at this time. Exit interview, report read, citation issued, appeal rights and report provided.the state’s words, verbatim · CDSS document, Jun 25, 2025 · control 29-AS-20250618090543

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87217(i) · Plan of correction due date: Jun 26, 2025

87217(i) Upon discharge of a resident, all cash resources, personal property and valuables of that resident which have been entrusted to the licensee shall be surrendered to the resident, or his responsible person. A signed receipt shall be obtained. This requirement was not met by evidence of Medication Delivery Record date and date specific medication was not provided to R1's representative. Which poses an immanent risk to residents in care.the state’s words, verbatim · CDSS document, Jun 25, 2025

Plan of correction: Administrator agreed to write a medication intake policy for facility that has time limits and double oversight by multiple staff for all medication intake. Emailed to LPA Jeffries on or before 06/26/2025.

Type of visit: Case Management - Other

At 11:20pm on 05/21/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to continue the investigation to a subsequent complaint. LPA met with, Administrator, Lisa Gerr announced who he is and the reason for the visit. LPA conducted a cursory tour of the facility. LPA conducted interviews with staff and attempted interviews with residents, and reviewed documentation. It was discovered that Direct Care Staff 1 (S1) had not been registered with Guardian and was not present on Licensing Information Systems (LIS) when checked during the complaint investigation visit. Administrator stated that S1 was cleared and associated, however it S1 did not appear on both background clearance cites. LPA assisted Administrator to attain S1's PERS number as was able to associate S1 during the course of the visit. Administrator stated that this was S1's first day. This resulted in a citation of S1 not being cleared for 1 day (87355(a)). During the complaint visit LPA requested Registry of Residents. Administrator stated the facility did not have a Register of Residents (LIC9020) upon demand during normal business hours resulting a citation issued (87508(b)). Administrator was able to create a new LIC9020 during the course of the visit. LPA issued two citations and a civil penalty as a result of this subsequent case management visit to the complaint report issued on the same day and visit. Exit interview, report read, citations and civil penalty issued, appeal rights and report provided.the state’s words, verbatim · CDSS document, May 21, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(a) · Plan of correction due date: May 22, 2025

87355 Criminal Record Clearance (a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review. This requirement was not met by review of current working staff S1 not being cleared in Guardian or LIS at time of visit. Which poses a risk to residents in care.the state’s words, verbatim · CDSS document, May 21, 2025

Plan of correction: Administrator associated S1 to Guardian at time of LPA complaint visit. POC cleared on visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87508(b) · Plan of correction due date: Jun 4, 2025

87508 Register of Residents (b)Registers of residents shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Registers may be removed if necessary for copying. Removal of registers shall be subject to the following requirements: Which is a potential danger to Residents in care. This requirement was not met by evidence of not having Register or Residents (LIC9020) upon demand during complaint visit on 05/21/2025.the state’s words, verbatim · CDSS document, May 21, 2025

Plan of correction: Administrator completed Register or Residents during complaint visit on 05/21/2025.

Type of visit: Case Management - Deficiencies

LPA Kristin Kontilis conducted a Case Management visit to address deficiencies noted during Complaint Control #29-AS-20250310083615 investigation visit conducted on 4/16/2025. The Case Management visit is being conducted to address CCLD’s concern that the Licensee accepted Resident 1 (R1), a non-conserved individual who currently resides in the locked memory care facility. Record review and interviews conducted revealed R1 does not have a dementia diagnosis and resident does not require the level of care provided by this facility. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Copy of report issued. Appeal Rights issued.the state’s words, verbatim · CDSS document, Apr 16, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(4)(B) · Plan of correction due date: Apr 18, 2025

87705(f)(4)(B) Care of Persons with Dementia (4) The licensee shall maintain either of the following documents in the resident's record, depending on the resident's conservatorship status: (B) A written statement signed by each non-conserved resident that states the resident understands that the facility has locked exterior doors or perimeter fence gates and that the resident voluntarily consents to such upon admission Based on interview and record review, the licensee did not comply with the section cited above when Licensee accepted a non-conserved individual who does not have a dementia diagnosis and does not require the level of care provided by the facility which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 16, 2025

Plan of correction: Administrator agrees to assist Resident in relocating out of the facility. Administrator agrees to provide written statement of agreement to assist in re-location of Resident. Administrator agrees to submit written statement acknowledging understanding of 87705 in its entirety. Administrator agrees to provide POCs via email to LPA.

Type of visit: Office

On this day at 11 am, a meeting was conducted by Assistant Program Administrator (APA) Stacy Barlow to verify Chapter 7 Bankruptcy Report filed by the Pacifica Senior Living as reported by the media. Present during the meeting are: Shelley Grace - Assistant Branch Chief, CCLD Craig Lundgren - Legal Counsel, CCLD Carl Knepler - Chief Executive Officer, Marlene Nelson - Director, Quality Assurance and Risk Management APA Barlow verified with Knepler information received by CCL from the media as follows: • $25M lawsuit against the community located in Bakersfield • Photography lawsuit against one of the properties • lawsuit against a Skilled Nursing Facility (SNF) in the Healdsburg location Knepler states that despite the lawsuits, there is no financial impact to any of the properties, residents or staff of the company. Knepler added there are no vendor issues as well. continuation on Lic 809C... Knepler also states that management communicates with the staff and residents to make them aware of the changes. Signages have been changed. Knepler added that the bankruptcy did not affect any of the communities because Pacifica Senior Living Management was no longer the management company for any of the Pacifica Communities, that the communities had given notice to the department and residents back in October or November of last year of the changes in management companies. He said that the judgment in Bakersfield did not involve the operating entity, only the management company. He said there were no other suits pending against any of the Pacifica entities. APA requested the following documents be provided to CCL by today: • Spread sheet of all facilities whose management company was/is Pacifica Senior Living Management Company • management companies for each location • letter provided to the residents notifying them of the changes At the conclusion of the meeting, APA emphasized to Knepler the importance of communicating with CCL any lawsuits that the company may have in the future. Knepler agreed with APA. A copy of this report was provided to Knepler.the state’s words, verbatim · CDSS document, Apr 4, 2025

Type of visit: Case Management - Deficiencies

This Case Management visit was conducted to address deficiencies noted during Complaint Control #29-AS-20250310083615 investigation visit conducted on 3/19/2025. The Case Management visit is being conducted to discuss the reporting of a death requirement as per regulation 87211(a)(1)(A) Reporting Requirements. During today’s visit, documents reviewed revealed on 3/11/2025 CCLD received LIC624A stating on 3/3/2025 Resident 1 (R1) passed away due to “metabolic encephalopathy and adult failure to thrive”. Administrator Gerr stated R1 was not on hospice and not reporting it within the seven day requirement was “an oversight”. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Mar 19, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)A · Plan of correction due date: Mar 20, 2025

87211(a(1)(A) Reporting Requirements: Each licensee shall furnish …(A) Death of any resident from any cause regardless of where the death occurred... This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above when death of a resident on 3/3/2025 was not reported to CCLD until 3/11/2025 which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 19, 2025

Plan of correction: Administrator agrees to provide written statement acknowledging the requirement of providing LIC624A Death Report within the required time. Administrator agrees to submit written statement directly to LPA via email no later than POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Required Inspection of the facility. At the time of arrival, there were fourteen (14) residents in care and two staff, Business Office Manager, and Administrator Lisa Gerr on duty. LPA met with Lisa Gerr, Administrator and explained the purpose of the visit. Entrance interview conducted: The facility is a one-story Residential Care Facility for the Elderly (RCFE) with a capacity of thirty-six (36) residents. The facility is a memory care facility for residents with a dementia diagnosis. The facility has a fire clearance for thirty-six (36) non-ambulatory residents of which thirty-six (36) can be bedridden and has a hospice waiver for ten (10) residents. Currently, there are two (2) residents on hospice and no bedridden residents residing in the facility. LPA and BOD toured the facility to assess the physical environment and accommodations. The following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. Upon entry, there is a gate that requires a code to enter the premises and a phone number posted to the facility for those who do not have a code. Entering through the gate, is a large walkway and driveway leading up to a large front patio with seating areas including patio chairs, tables with umbrellas, couches, and mini-couches. Entering past the patio area, the administrator’s office is located on the west side of the building. Staff files and other confidential information is kept in the administrator’s office. Entering into the main area of the facility is the dining area/common area on the east side of the room. Socializing, meals, and activities are held in the dining/common area. Please continue to 809-C, Pg 2. The kitchen is located at the back of the dining/common area and is inaccessible to residents in care. LPA observed seven (7) days of non-perishable food items and two (2) days of perishable food items. LPA observed approximately 16 heads of iceberg lettuce loosely in a box without proper packaging and date stamped. LPA reviewed Resident 1's (R1's) hospice file and determined no hospice notification has been submitted to CCLD within five (5) business of having been placed on hospice. At approximately 3:19 pm, LPA reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster. Record review revealed Staff 1 (S1) has worked in the facility since 8/23/2024 and has not been properly associated to the facility prior to employment; Staff 2 (S2) has worked in the facility since 11/1/2024 and has not been properly associated to the facility; and, Staff 3 (S3) who was hired on or about 10/16/2024 has not been properly associated to the facility. Due to time restraints, LPA will return at a later date to continue the annual inspection. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. Due to technical difficulties, copy of report and Appeal Rights issued via email.the state’s words, verbatim · CDSS document, Feb 24, 2025

Allegation investigated: Staff do not ensure that residents are provided activities while in care. Staff do not adhere to resident's special diet as prescribed. Staff do not ensure that resident is provided their medication(s) as prescribed.

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to deliver final findings for the above allegation. LPA Philips started the investigation on 3/6/2024 from 1:30pm to 3:30pm. During today’s visit, LPA Rankin met with Cynthia Garcia, administrator, and Elizabeth Hernandez, Designee, explained the reason for the visit. LPA toured the facility, reviewed relevant documents, and interviewed administrator, staff, and residents. On the allegation: Staff do not ensure that residents are provided activities while in care. It was alleged that activities were not provided. However, reporting party also stated activities are provided, but they thought the activities could be improved. On 3/6/2024, LPA observed activities available for residents including board games, puzzles and reading materials in the common room. Continued on 9099-C Unsubstantiated On 5/6/2024, 6/3/2024 and 6/11/2024, LPA observed activities occurring in the common room area. Administrator provided an activities calendar and stated they typically follow the calendar closely, unless one activities is more engaging or preferred by residents. Residents interviewed stated they liked the activities provided and usually participate. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff do not adhere to resident's special diet as prescribed. It was alleged that Resident 1(R1) had a special diet prescribed as a result of a medication being taken, but the special diet was not implemented. LPA reviewed the special diet forms in the facility and did not observe one for R1. Administrator and memory care director fill out the forms, sign it and have the dietary director sign. The form includes the resident’s name, picture, special diet description and effective date. Administrator stated they clarify special diet orders when needed, such as recently clarifying a “no dessert” order to see if fruit or sugar free ice cream was acceptable. Administrator stated they immediately review orders for special diets and implement them. LPA reviewed R1’s file and did not see an official order for a special diet. However an after visit summary did indicate a bland diet after vomiting. R1’s responsible party did not respond to LPA’s request for interview. Based on the information obtained, there was insufficient evidence to prove the allegation occurred. Therefore the allegation is deemed Unsubstantiated at this time. On the allegation: Staff do not ensure that resident is provided their medication(s) as prescribed. It was alleged that medication information was not passed between shifts. Administrator stated they use end of shift reports to communicate information about residents to the next shift. Administrator stated when a new medication or order is received, the order is usually faxed or emailed to the facility. Alternatively, if the order is sent directly to the pharmacy, they follow up with the pharmacy and/or doctor to obtain a copy of the written order. Administrator stated updates in orders get updated directly in their Quickmar system. Administrator stated if medications are discontinued, the medications get archived in the Quickmar. Continued on 9099-C When staff notice that a medication is discontinued, they turn the bubble pack around and bring it up to management. The resident care coordinator or memory care directly pull the bubble packs and follow discontinued medication procedures to destroy it. New orders are also put in the binder sticking out to notify other staff of changes. LPA reviewed medications and observed discontinued medications in the Quickmar. Based on the information obtained, there was insufficient evidence to prove the allegation occurred. Therefore the allegation is deemed Unsubstantiated at this time. Exited interview done, copies of report given to Designee.the state’s words, verbatim · CDSS document, Jun 11, 2024 · control 29-AS-20240227112010

Allegation investigated: Due to neglect, Resident became septic while in care

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to deliver final findings for the above allegation. The initial visit was conducted on 06/17/2022 by LPA Kristin Kontilis. During today’s visit, LPA Rankin met with Cynthia Garcia, Administrator, and explained the reason for the visit. On the allegation: Due to neglect, Resident became septic while in care. On 06/16/2022, the Department received a complaint alleging that former facility Resident #1 (R1) became septic while residing at the facility as a result of facility neglect. On 06/17/2022, between 1:10pm and 4:00pm, LPA Kontilis conducted the initial complaint visit. Continued on 9099-C Substantiated During the visit, the LPA conducted a physical tour of the facility and requested and obtained documents pertinent to the investigation. The Administrator at the time was notified that the complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Jose Santana for further investigation. Investigator Santana conducted interviews on 07/06/2022, at approximately 4:00pm, with R1’s resident representative; on 07/12/2022, from approximately 1:05pm to 3:30pm, with facility staff; on 07/13/2022, from approximately 7:00am to 3:30pm, with facility staff, Memory Care Director and former facility Executive Director; on 07/18/2022, at approximately 11:00am, with Memory Care Director; on 08/02/2022, at approximately 5:05pm, with Cottage Hospital attending physician; on 08/05/2022, at approximately 6:50pm, with Cottage Hospital attending physician; on 08/09/2022, at approximately 3:40pm, with R1’s resident representative; on 08/23/2022, at approximately 10:25am, with Central Coast Home Health Services (CCHS) and on 08/24/2002, at approximately 10:30am, attempted interview with R1’s Primary Care Physician (PCP). Additionally, Investigator Santana obtained and reviewed copies of R1’s facility file documents, hospital records and home health records. On 12/24/2020, at 3:46pm, R1 arrived at Santa Barbara Cottage Hospital (SBCH) via ambulance for a sudden onset of difficulty in breathing, according to the Skilled Nursing Facility where R1 was residing. While at the hospital, R1 was diagnosed with COVID-19, anasarca, hypoalbuminemia, hypokalemia, among other conditions. R1’s sepsis screen showed a suspected infection, and a urinalysis showed an abnormal result. R1 had also previously had sepsis on 09/17/2020. R1 had a history of diabetes mellitus, high cholesterol, and hypertension, along with atrial fibrillation, gastritis, hiatal hernia with GERD, cholelithiasis, Schatzki’s ring, and prior alcohol abuse with liver disease. Continued on 9099-C On 01/01/2021, SBCH attempted to locate skilled nursing facilities that would accept R1. The hospital records also noted physical therapy was attempted with R1, but R1 declined to participate, saying they were “too tired”. On 01/04/2021, R1 was diagnosed by the hospital registered dietician (RD) who noted R1’s malnutrition was likely related to multiple chronic medical issues as evidenced by weakness, prior weight loss, and ongoing inadequate oral intake; R1’s nutrition risk level was moderate. R1’s blood glucose was being controlled with R1’s current insulin regimen and carb-controlled diet. The RD suspected R1’s appetite would improve as acute issues improved and R1 was in a more comfortable environment. On 01/05/2021, the attending physician noted that R1’s prognosis had been full recovery back to baseline of underlying dementia. On 01/06/2021, the case manager informed R1’s resident representative that no skilled nursing facilities were accepting residents in the area. R1’s resident representative advised that they were considering placement at the Pacifica Senior Living facility. The facility administrator agreed to admit R1 the following day on 01/07/2021. R1 was discharged from the hospital on 01/07/2021 at 3:41pm. A review of the Physician Report, dated 01/07/2021, completed by the SBCH attending physician, noted R1’s primary diagnosis as anasarca, with secondary diagnoses of atrial fibrillation, anemia, GERD, and cirrhosis. The accompanying medication standing orders listed only over-the-counter medications to be taken as needed. The Pre-Placement Appraisal, dated 01/07/2021, also completed by the same SBCH physician noted that R1 had the following conditions and listed the medications that R1 was prescribed at that time: Aspirin for atrial fibrillation, Bumex for HFPEF and anasarca, Lactulose for cirrhosis, Protonix for GERD, Folic Acid for anemia, and Levemir and sliding scale Aspart for diabetes. An administrator for CCHHS stated sometimes hospital discharge records list all medications given to patients in the hospital, which are not necessarily meant to continue taking upon discharge. CCHHS personnel stated they did not have a list of medication from the hospital that says what medications R1 was to take upon discharge. CCHHS paperwork states per Cottage Health, “you have not been prescribed any medications.” Continued on 9099-C However, upon further investigation CCL located a medication discharge list on the Interfacility Transfer After Visit Summary from Cottage Hospital, that neither the facility nor CCHHS had in their possession. The Interfacility Transfer Medications included Bumex to be given twice daily from 01/07/2021 at 9:00pm until discontinued, insulin aspart pen injection 0-10 units to be given on a sliding scale four times daily and nightly from 01/07/2021 at 12:00pm until discontinued, and insulin determir pen injection 15 units to be given daily from 01/08/2021 at 9:00am until discontinued, among other medications. On 01/13/2021, CCHHS completed their initial assessment of R1. R1’s primary diagnosis was COVID-19 acute respiratory disease, but other diagnoses included type 2 diabetes mellitus without complications, hypertension, and hyperlipidemia. R1 was noted as being diabetic without insulin dependence. R1 was also noted as not taking any medication with the exception of over-the-counter and herbal medications. CCHHS had orders for skilled nursing, physical therapy, and occupational therapy. There were also orders for social work because R1’s resident representative was concerned that R1 was not prescribed the correct medications at the facility. The facility reported R1 was consuming smoothies alone, so CCHHS ordered a nutrition evaluation because of R1’s decreased appetite and weight loss. The facility reported R1 was only eating twice a day. R1’s physician orders called for a low carb diet with no concentrated sweets. During the skilled nursing visits on 01/13/2021, 01/20/2021, 01/26/2021 and 01/27/2021, staff reported to the nurse that R1 had bowels movements on those dates. Physical therapy was attempted with R1 on 01/15/2021 and 01/20/2021, but R1 resisted and refused. On 01/21/2021, R1 was assigned a new PCP and had a tele-health visit with R1’s resident representative to review R1’s recent hospitalization, recent events, as well as past medical history and goals of care. PCP was aware that R1 was “apparently not receiving any medication as listed on the physician’s report”. Following the tele-health visit, PCP ordered a speech therapy consult and an order for an RN to check R1’s vitals and to report R1’s blood glucose. On 01/28/2021, PCP ordered for CCHHS to call R1’s family member “to assist with lab draw if patient uncooperative”, and prescribed Bumex along with over-the-counter medications. Continued on 9099-C On 02/01/2021, staff found R1 on the floor in their bedroom. R1 was assessed for injuries and 911 was called due to R1 complaining of pain. Emergency Medical Services (EMS) arrived at 3:57pm and transported R1 to SBCH. R1 was hospitalized at SBCH for evaluation of bruising and swelling to the left upper chest. Chief complaints were abrasions as a result of the fall out of a wheelchair. Medics reported a blood glucose of 499. Per hospital records, skin tears and ecchymosis were noted to bilateral forearms. Medics also reported R1 does not take any prescription medications. R1’s diagnoses included sepsis due to a urinary tract infection (UTI), hematoma of the left chest wall, acute retention of urine, and stage 3 chronic kidney disease, among other conditions. A CT scan was taken of chest, abdomen, and pelvis showed a large anterior left chest wall hematoma without associated fracture, moderate stool burden throughout the colon correlates for constipation and predominately sub-diaphragmatic/perihepatic ascites on the right, which was new compared to the previous study and is of unknown etiology. R1 had clinical signs for dehydration that included dry mucous membranes, tachycardia, and abnormal vital signs. R1 required a large volume of rapid fluid resuscitation through IV. R1 had urinary retention that was alleviated when a Foley catheter was inserted and drained greater than 1500 cc of urine. This was consistent with an infection and was confirmed by R1 having an elevated white blood count, procalcitonin, and lactate levels. Antibiotics and fluids were ordered along with 10 units of insulin. On 02/02/2021, R1 was discharged to home and placed on hospice. The medical records reviewed indicate that R1’s sepsis resulted from a UTI. The SBCH treating physician advised that R1’s sepsis was caused by a UTI that may have been caused in part by effects of unmanaged diabetes. The facility failed to notice R1’s diabetes diagnosis, which was clearly listed on R1’s pre-placement appraisal at the time of admission to the facility on 01/07/2021. The former facility administrator stated that R1 had no prescriptions at the time of admission, but had the facility known that R1 required insulin, as is indicated on the pre-placement appraisal, the facility would not have admitted R1 without home health in place for a nurse to administer it. Continued on 9099-C It was clear from the 01/07/2021 hospital discharge documentation that the attending physician intended for R1 to have regular labs, and these recommendations were sent to CCHH at the time of hospital discharge. For reasons unknown, home health did not initiate home health services until 01/13/2021, which was nearly a week after R1’s facility admission. R1’s resident representative raised concerns at least by 01/15/2021 that R1 was perhaps not receiving their intended medications and the Memory Care Director agreed to look into the situation. However, the Memory Care Director had no recollection of this conversation and admits that she made no follow up. R1 did not have a primary care physician (PCP) to prescribe medications, and it was not until 01/21/2021 that R1’s new PCP saw R1. PCP prescribed several of the medications the SBCH attending physician had recommended for R1 (with the notable exception of insulin) on 01/28/2021. Ultimately, the facility had the responsibility to follow up on the medication discrepancy once R1’s resident representative advised that there was an issue. Additionally, the administrator should have noticed the discrepancy between diabetes and insulin listed in the preadmission appraisal, and the fact that r1 had no prescribed routine medications. Since the facility failed to do so, this likely contributed to the medical problems that manifested on 02/01/2021 since R1’s several chronic conditions were, in effect, not being treated from 01/08/2021 to 01/27/2021. The allegation that R1 became septic as a result of facility neglect in part because of the facility’s failure to help secure appropriate medications in a timely manner is therefore Substantiated at this time. The Cynthia Garcia was informed that the case will be reviewed and it is possible civil penalties could assessed based on Health and Safety Code 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Jun 11, 2024 · control 29-AS-20220616085421

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Jun 12, 2024

Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited when they failed to ensure R1’s medication needs were being met,the state’s words, verbatim · CDSS document, Jun 11, 2024

Plan of correction: Licensee will submit plan to ensure residents’ needs are being met Submit to CCL by 6/12/24. which resulted in R1’s chronic conditions not being treated from 01/08/2021 to 01/27/201, which posed an immediate health and safety risk to residents in care.

Allegation investigated: Due to neglect, Resident was dehydrated Due to neglect, Resident suffered a fall while in care Resident was vaccinated without consent Facility did not notice a change in resident’s condition Facility not allowing resident to communicate with family members

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to deliver final findings for the above allegation. The initial visit was conducted on 06/17/2022 by LPA Kristin Kontilis. During today’s visit, LPA Rankin met with Administrator Cynthia Garcia and explained the reason for the visit. On the allegation: Due to neglect, Resident was dehydrated. It was alleged R1 was diagnosed with dehydration. Staff interviewed stated one of the med tech’s job duties is to track resident’s bowel movements. Staff stated if a resident does not have a bowel movement for two days, then stool softeners may be provided with a doctor’s order. Continued on 9099-C Unsubstantiated If the resident had not voided, then the med tech would notify their supervisor, because this could mean the resident was dehydrated. Staff interviewed stated they encourage residents to take in liquids throughout the day, and ensured residents had cups of water accessible to remain hydrated. However sometimes the residents do not take in the liquid provided. When this happens, staff notify the resident’s family and doctor, and the administrator. Staff stated by the third day of a resident refusing to take in liquids, the facility would send the resident to the hospital for evaluation. Staff stated they are trained to look for signs of a Urinary Tract Infection (UTI), which could include increased confusion, not eating, and an odor. Staff also stated they notify the resident’s family and doctor for any change in condition. Staff stated they did not recall specifics about R1’s bowel movements. However, one staff stated they remembered R1 drank lots of liquids and urinated a lot. R1 asked for fruit smoothies often, and indicated R1 finished every drink staff provided them. Former Administrator stated they recalled R1 wore briefs due to incontinence and required a two-person assist to change the briefs. Former Administrator stated R1 would have been changed before and after meals. Former Administrator did not recall R1 having an issue with constipation, nor remembers discussing with staff that R1 was not urinating or defecating. Former Administrator stated staff knew to report something like that to her. Former Administrator also stated staff knew to report if a resident was not eating. R1 was declining foods but was still drinking smoothies, Ensure, and water, and Former Administrator was never informed R1 had stopped taking liquids. Former Administrator stated R1’s family knew R1 was not eating solids, and allegedly told Former Executive Director that R1 could consume smoothies instead. Former Executive Director stated R1 liked milkshakes and would ask for things to drink. Former Executive Director also noted that beverages are also given out even when not requested, to keep residents hydrated. Former Executive Director noted R1 preferred liquids over solids more than most residents. It is documented in hospital records on 1/5/21 (prior to facility admission) that R1 “really likes the protein shakes, does not like solid food, poor appetite.” Hospital records also showed that R1’s family was aware they preferred liquid foods to solids before R1 moved into the facility. Continued on 9099-C R1’s care plan dated 1/10/21 also notes that R1 like smoothies, staff should encourage R1 to eat as much as they can, family states R1 is not eating much, and please encourage liquids and smoothies. Bowel logs for R1 were unavailable at the time of the complaint. Bowel logs reviewed in July 2022 showed that several of the logs were incomplete, with several having entries only for the morning shift. Hospital records indicate R1 had clinical signs for dehydration that included dry mucous membranes, tachycardia, and abnormal vital signs. R1 required a large volume of rapid fluid resuscitation through IV. However, a hospital physician who treated R1 was interviewed and stated R1 had urine retention, but was still making urine and therefore was taking in fluids due to the amount of urine in their bladder. Based on the information obtained, there was insufficient evidence to prove the resident was dehydrated. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Due to neglect, Resident suffered a fall while in care. It was alleged that due to a lack of care and supervision, R1 sustained a fall while in care at the facility. R1’s care plan dated 1/10/21 indicates they are a “fall concern,” and they required total assist with ambulation. Staff interviewed stated R1 was checked on every one to two hours. Multiple staff interviewed did not recall R1’s fall. R1 did not require a one to one staff person. R1 fell alone in their room and was found on the floor by staff on 2/1/21 at approximately 2:50pm. Staff called 9-1-1 and sought medical attention for R1, who complained they were in pain. Based on the information obtained, there was insufficient evidence to prove that a lack of care and supervision lead to R1’s fall. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Resident was vaccinated without consent. It was alleged that R1 received a COVID-19 vaccination without consent. R1’s family member (F1) stated they were notified that residents in the facility would receive the COVID-19 vaccine. Continued on 9099-C F1 stated they promptly contacted the facility to inform them R1 was previously diagnosed with COVID-19 one month earlier, and per Centers for Disease Control (CDC) guidelines, they should not be vaccinated for at least 3 months after being diagnosed. Per F1, the facility informed them the guidelines had changed and it was ok to give R1 the vaccine, so R1 received it. Per F1, the next day R1 fell out of their wheelchair, landed on their back, and went to the hospital. F1 stated they believe receiving the vaccine they did not need caused R1’s health to decline. Faily member 2 (F2) was interviewed and stated R1 received the first vaccination dose in the hospital and did not respond well. F2 stated based on that and CDC guidance, they told the facility R1 should not receive the second dose. F2 was unaware that the facility vaccinated R1. Resident’s vaccine card and vaccination status were not provided in the documents obtained. There was insufficient evidence to prove the allegation occurred. Therefore the allegation is deemed Unsubstantiated at this time. On the allegation: Facility did not notice a change in resident’s condition. R1’s family member (F2) stated that although R1’s condition declined, R1’s responsible party was not notified of the decline that occurred during their last 2 weeks at the facility. F2 stated the facility did not inform them that R1 was not eating and was not voiding, and that their health was declining. F2 believes that R1 not urinating or having bowel movements should have been an indication something was wrong. F2 also indicated R1 had a history of not wanting to eat, which started at the prior Skilled Nursing Facility (SNF). It is documented in hospital records on 1/5/21 (prior to facility admission) that R1 “really likes the protein shakes, does not like solid food, poor appetite.” Hospital records also showed that R1’s family was aware they preferred liquid foods to solids before R1 moved into the facility. R1’s care plan dated 1/10/21 also notes that R1 like smoothies, staff should encourage R1 to eat as much as they can, family states R1 is not eating much, and please encourage liquids and smoothies. Staff interviewed recalled that when R1 first moved in, they ate any of the food prepared. However, staff stated there came a time when R1 did not want to eat any more. When this happened, staff offered R1 other options, and noted that R1 liked juice and would often as for it. Continued on 9099-C Staff also stated R1 was never combative, which could have been an indicator of a UTI. Former Executive Director stated when making rounds on 2/1/2021, they noted R1 “didn’t look so good” and was pale, and did not seem like themselves. The morning shift had not reported any changes with R1. However, Former Administrator stated R1’s baseline was very weak and R1 could barely talk. Former Administrator indicated they did not feel that R1 was declining, and they appeared the same throughout their time at the facility. The Emergency Medical Services report only states R1 was transported due to being found of the floor, and does not note any additional concerns about R1 or their appearance. Bowel logs for R1 were unavailable at the time of the complaint. Bowel logs reviewed in July 2022 showed that several of the logs were incomplete, with several having entries only for the morning shift. The facility did not chart fluid intake on any written document, but the hospital physician confirmed they believed R1 drank a lot of fluid based on the amount of fluid in their bladder upon admission to the hospital. F2 stated the facility was not proactive in communicating with family. When F2 called, they asked staff how R1 was and was not notified she was declining. F2 believes R1 had to decline in order to be sent home on hospice after being in the hospital. However, R1’s ER doctor stated R1 should have been on hospice when they entered the facility, and staff stated they did not notice any change in condition. Although the allegations may have happened, there was insufficient evidence to prove the allegations occurred. Therefore the allegations are deemed Unsubstantiated at this time. On the allegation: Facility not allowing resident to communicate with family members. It was alleged that R1 was not allowed to have visitors due to COVID-19 restrictions. R1’s family member (F1) stated they had some phone calls with R1 and a couple of Skype calls. However, the last two weeks R1 was at the facility, they had no contact. Per F1, staff stated R1 was sleeping when they called, or no one was available to initiate the call or the iPad was not available. Interview with R1’s family member (F2) revealed due to COVID-19, they were able to call R1 but sometimes no staff were available to assist R1 with video calls. Continued on 9099-C Upon re-interview, F2 stated staff would say R1 was sleeping, bathing, or eating dinner when they called, or the iPad was unavailable. However, no other interviews corroborated this information. Although the allegations may have happened, there was insufficient evidence to prove the allegations occurred. Therefore the allegations are deemed Unsubstantiated at this time. Technical assistance is provided to the facility to ensure there are adequate and competent staff to allow residents to communicate with family members via telephone or video conference platforms. Continued on 9099-Cthe state’s words, verbatim · CDSS document, Jun 11, 2024 · control 29-AS-20220616085421

Allegation investigated: Staff did not notice a change in resident’s condition. Staff did not assist resident in care with their hygiene needs. Staff did not administer medication(s) to resident according to physician's instructions. Staff did not feed resident while in care. Facility did not have enough staff to meet the needs of resident(s) in care. Staff did not respond to resident's representatives requests for assistance. Staff did not notify resident's representative about resident's change in condition.

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Cynthia Garcia Administrator and explained the purpose of the visit. During the investigation, LPA Kontilis conducted the initial visit on 11/14/22, obtained relevant documents, and interviewed staff. On the allegations: Staff did not notice a change in resident’s condition, Staff did not respond to resident's representatives requests for assistance, and Staff did not notify resident's representative about resident's change in condition. R1’s family member (F1) stated R1’s hospice social worker indicated they found a less expensive facility for R1, but did not state this was a facility for people who were at the end of life. Continued on 9099-C Unsubstantiated F1 also stated R1’s hospice nurse did not tell them this either. F1 stated they were promised by the hospice nurse they would discuss any changes in R1’s care with them, but F1 was never contacted about anything. F1 stated when she told the facility’s now former Executive Director (ED) about the issues, the ED suggested to have a meeting with R1’s providers. F1 stated on 10/2/20 they saw R1 in an ambulance and realized R1 was dying. F1 said they had not received any word of R1’s condition from the hospice social worker or hospice nurse, and R1’s body again smelled like rotting flesh. R1’s hospice nurse and hospice social worker did not work for the facility. Although the allegations may have happened, there was insufficient evidence to prove the allegations occurred. Therefore the allegations are deemed Unsubstantiated at this time. On the allegation: Staff did not assist resident in care with their hygiene needs. F1 indicated during R1’s last week at the facility, their “skin has the smell of rotten flesh.” F1 asked staff if R1 was being cleaned, and staff said yes. F1 stated on 10/2/20, they saw R1 in an ambulance and realized R1 was dying. F1 stated R1’s body again smelled like rotting flesh, and they believe because R1 was “rotting from the inside.” F1 said they had not received any word of R1’s condition from the hospice social worker or hospice nurse. F1 believed R1 was not bathed on the weekends. R1’s physician’s report dated 8/15/2019 indicates R1 needs assistance with bathing. R1’s hospice care plan dated 6/15/2020 indicates R1 needs assistance with bathing in the shower. An updated facility care plan dated 9/15/2020 indicates R1 needs 2 person assist with bathing and it was performed by an outside agency (hospice). Another page of the document confirms it was hospice’s responsibility to shower R1 three times per week per the care agreement. There was no documentation or notes in R1’s files to suggest they refused bathing or were not bathed regularly. Although the allegation may have happened, there was insufficient evidence to prove the allegation occurred. Therefore the allegation is deemed Unsubstantiated at this time. On the allegation: Staff did not administer medication(s) to resident according to physician's instructions. It was alleged that R1 was not provided their medications as prescribed. Continued on 9099-C F1 stated that the administrator called them to notify them R1 fell out of bed, was picked up and put back to bed without waking. F1 indicated there was a second incident where R1 fell out of bed onto the floor without waking. F1 stated they think R1 could have been overmedicated. Per F1, R1’s personal doctor called them also stating the concern of being overmedicated. F1 indicated when R1 entered the facility, they could walk, talk and feed self, and two weeks later they could not do any of those things. Previously R1 could video chat every day, but after they could not lift their head to talk and was often sleeping. F1 also stated medications that were discontinued were still given by staff that were unaware of the change. F1 stated that R1’s hospice nurse made a remark that they could take all of R1’s medications away and “let nature take it’s course,” and F1 also stated they believe the hospice nurse did stop giving R1 medications. LPA reviewed medication orders for R1 dated 6/15/2020, and reviewed documentation in R1’s file. There was no documentation to suggest medication was not given as prescribed. LPA reviewed incident reports for 2020 and did not find any report of medication not given as prescribed. Although the allegation may have happened, there was insufficient evidence to prove the allegation occurred. Therefore the allegation is deemed Unsubstantiated at this time. On the allegation: Staff did not feed resident while in care. It was alleged staff did not feed a resident in care. F1 stated they were told R1 was actively dying and saw R1 writhing in pain. F1 believed R1 was not dying, but was having hunger pains. F1 stated a staff told them the facility staff have no patience feeding the residents. F1 stated one evening they went to visit R1 at 5:30pm and were told R1 was already in bed and did not eat dinner. F1 indicated R1’s hospice nurse told staff not to feed R1. F1 asked R1’s hospice nurse if R1 could be taken to the hospital to get fluids, but was told hospice does not do that. F1 brought protein shakes for R1 but stated they were not given to R1. R1’s physician’s report dated 8/15/2019 states they are “borderline” able to feed themselves. R1’s hospice care plan dated 6/15/2020 indicates R1 feeds self. On subsequent visits to the facility, LPAs observed an adequate amount of food in the kitchen on annual inspections on 2/25/2022, 2/21/2023, and 1/30/2024. Continued on 9099-C No staff interviewed indicated residents’ care needs were not met. Although the allegation may have happened, there was insufficient evidence to prove the allegation occurred. Therefore the allegation is deemed Unsubstantiated at this time. On the allegation: Facility did not have enough staff to meet the needs of resident(s) in care. F1 stated they did not believe there was enough staff for their staff to patient ratio. F1 stated they watched a resident sit alone on the patio for a half hour and staff did not come check on them. F1 believes this is because the staff must supervise, feed and clean residents, clean up after meals and do housekeeping duties. LPA was unable to determine which resident F1 described. On a visit on 5/6/2024, LPA observed a resident sit outside on the patio and observed staff routinely check on the resident through the windows. Former Administrator stated around 2020, there were only two staff working the afternoon shift. Former Administrator stated they asked for more staffing, but corporate did not approve it at the time. Staffing was increased in March 2022 so that both the morning and afternoon shift had two caregivers and one med tech. Former Administrator stated when they had fewer staff on shift, she worked the floor and staff members worked overtime to ensure residents were cared for. Former Administrator stated they ensured resident care was not affected, saying it was hard on the staff but nothing fell through. Although the allegation may have happened, there was insufficient evidence to prove the allegation occurred. Therefore the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Jun 11, 2024 · control 29-AS-20221104125523

Allegation investigated: Staff did not provide resident's responsible party with records after requested. Staff did not allow visitor(s) into the facility in a timely manner.

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Cynthia Garcia, Administrator and explained the purpose of the visit. During the investigation, LPA Kontilis conducted the initial visit on 11/14/22, obtained relevant documents, and interviewed staff; R1’s family member was also interviewed. On the allegation: Staff did not provide resident's responsible party with records after requested. R1’s family member (F1) stated they requested a copy of R1’s chart in October 2020, and August 3 (year not specified). Continued on 9099-C Substantiated They requested it again in July 2022 and have tried to reach the facility via phone call, texts and messages but had not received the records. F1 was contacted on 6/7/24 and they indicated they still have not received R1’s records. The facility has had a change in personnel since the original request. The facility was notified during the visit that F1 would still like a copy of R1’s records. Based on the information obtained, the allegation was deemed Substantiated at this time. On the allegation: Staff did not allow visitor(s) into the facility in a timely manner. F1 stated multiple visitors to R1 experienced long wait times at the facility’s front gate, up to 45 minutes to an hour for staff to answer it. On multiple occasions, CCL staff has also encountered a long wait time at the front gate, including most recently on 6/3/24. On 6/3/24, after at least 10 minutes of waiting and calling various phone numbers, LPA had to use the code facility management had previously provided in order to gain access to the facility. Based on the information obtained, the allegation was deemed Substantiated at this time. Exit interview, deficiencies cited on 9099-D, report given, appeal rights given.the state’s words, verbatim · CDSS document, Jun 11, 2024 · control 29-AS-20221104125523

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Jun 18, 2024

Personal Rights. To have their visitors…permitted to visit privately during reasonable hours and without prior notice…This requirement was not met as evidenced by: Based on interview and observation, the licensee did not comply with this section when visitors were not let into the facility timely to visit, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 11, 2024

Plan of correction: Manager agreed to submit a written plan to ensure all visitors to the facility will be let in in a timely manner. Submit plan by 6/18/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Jun 13, 2024

Personal Rights. To have prompt access to review all...records and to purchase photocopies of all their records. Photocopied records shall be provided within two (2) business days… This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with this section when F1 was not provided R1’s record, which posed athe state’s words, verbatim · CDSS document, Jun 11, 2024

Plan of correction: Manager agreed to provide the records to F1 by 6/13/24. potential personal rights risk to residents in care.

Allegation investigated: Staff did not ensure a safe environment for residents in care. Staff did not ensure a sanitary environment for residents in care. Staff did not ensure that residents were provided with clean linens while in care.

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to deliver final findings for the above allegation. The initial visit was conducted on 12/5/2022 by LPA Kristin Kontilis. During the investigation, LPA toured the facility and interviewed staff. LPA also collected and reviewed relevant documents. During today’s visit, LPA Rankin met with Cynthia Garcia and explained the reason for the visit. On 11/26/2022, facility staff called first responders for assistance due to a resident falling. Multiple first responder agencies visited the facility as a result of this incident. Multiple patients were taken to hospital due to concerns for their health and safety. On the allegations: Staff did not ensure a safe environment for residents in care, and Staff did not ensure a sanitary environment for residents in care. Continued on 9099-C Substantiated A credible witness (W1) observed a dirty diaper in the facility hallway. W1 observed one room to have old, dried feces that appeared to be more than a day old as it was hard and thick. A bathroom room of two resident had black feces in the toilet still appeared to have not been flushed for hours. W1 also observed feces on the main hallway that was old, hard and dried. Another bathroom had an old, used diaper lying next to the toilet. Former Administrator reported staff check residents and their rooms every 2 hours, and some residents every hour, but these health and safety issues were observed and appeared to be at least one day old. The facility had no cleaning logs. W1 indicated Former Administrator discussed the diapers in the hallway with staff, and they did not have an excuse or reason, and admitted this was not accepted. Former Administrator reported cleaning occurs once per week by a housekeeper, and they also have developmentally disabled volunteers assist with cleaning. Former Administrator reported facility was cleaned three times per week, but admitted areas must have been missed and agreed it was a health hazard. LPA observed photographs of the dried feces on the floor, the unflushed toilet. Based on the information obtained, the facility did not provide a safe or sanitary environment for the residents. Therefore the allegation is deemed Substantiated at this time. On the allegation: Staff did not ensure that residents were provided with clean linens while in care. A credible witness observed one room had bed linen covered with some blood and had not been cleaned. LPA observed a photograph of the soiled linen. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Staff did not respond to resident's change of condition in a timely manner. It was alleged that credible witnesses found one resident (Resident 1 – R1)down on the found. Per credible witness interview with Former Administrator at time of incident, R1 fell and hit their head on 11/26/2022. Later in the day, R1 became unresponsive so staff called 9-1-1. Once R1’s change in condition of unresponsiveness occurred, facility staff contacted 9-1-1 for additional assistance. Staff notified first responders of other medical issues that occurred while first responders were present. Although the allegation may have occurred, there was insufficient evidence to prove it. Therefore the allegation is deemed Unsubstantiated at this time. Technical assistance is provided to remind the facility to observe residents who hit their head, and of their responsibility to seek timely medical attention despite residents may not be reliable narrators due to their dementia diagnoses. On the allegation: Staff did not meet the needs of residents in care. It was stated that multiple residents were found dehydrated and possibly malnourished. Other interviews conducted stated staff always put liquids in front of residents and encourage them to drink. Staff also stated residents refusing to eat is reported to management, where it will be addressed with the resident’s physician. A credible witnesses found one resident (Resident 1 – R1) down on the found. Per credible witness interview with Former Administrator at time of incident, R1 fell and hit their head on 11/26/2022. Later in the day, R1 became unresponsive so staff called 9-1-1. Resident 4 (R4) was found on the toilet unresponsive, and staff asked first responders to evaluate R4 due to the unresponsiveness. R4 was transported to the hospital as well. Resident 2 (R2) was observed down while first responders were in the building treating R1. Former Administrator stated they believed R2 should not have been taken as they were discharged back the same day. Records and interview did not indicate any serious injury R2. Resident 3 (R3) was then observed by staff to have difficulty breathing and first responders observed it as well so R3 was transported to the hospital. Former administrator reports that family and staff were aware of R3’s breathing issues and were managing their medical care, and R3’s family did not want them to go to the hospital. Continued on 9099-C Former Administrator stated Resident 5 (R5) was also transported due to an injury to their hand (fractured finger) but R5 previously had the fall and broken finger, and R5 was on hospice so they should not have been transported. Following the incident, a credible witness visited the facility. They observed 21 residents, mostly in the common areas. Residents appeared to be wearing clean clothes, well-groomed, good hygiene, and no smell of urine or feces was detected or observed. LPA reviewed incident reports submitted around the time of the complaint. On 11/26/2022, the Administrator performed mass COVID-19 testing and found nineteen of the twenty residents were positive for COVID-19. Although it is unusual that multiple residents would require medical attention at once, the allegation was unable to be proven conclusively. Therefore the allegation is deemed Unsubstantiated at this time. On the allegation: Facility staff provided inadequate supervision to residents. Per a credible witness’ interview, Former Administrator indicated for the 21 residents, during the day there are 3 care staff and there are 2 overnight. A credible witness observed 21 residents, mostly in the common areas. Residents appeared to be wearing clean clothes, well-groomed, good hygiene, and no smell of urine or feces was detected or observed. Although many issued occurred when first responders were at the facility, there was insufficient evidence found to prove that it was a result of inadequate supervision. Therefore the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Jun 11, 2024 · control 29-AS-20221201151546

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 18, 2024

Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on interviews and observations, the licensee did not comply with the section when the facility was not clean or safe, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 11, 2024

Plan of correction: Manager will provide a written statement of understanding of 87303.

Allegation investigated: Staff mismanaging residents medication. Facility toilet is in disrepair. Facility is dirty. Staff engaged in a verbal altercation in presence of residents.

Licensing Program Analyst (LPA) Rankin conducted an initial complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Rankin met with Cynthia Garcia, administrator, and Elizabeth Hernandez, Designee, explained the reason for the visit. LPA toured the facility, reviewed relevant documents, and interviewed administrator, staff, and residents. On the allegation: Staff mismanaging residents medication. It was alleged that a med tech was signing off that they provided medications without having provided them. LPA interviewed administrator about the allegation. Administrator stated the Memory Care Director brought up the issue and they had a meeting with all med techs to discuss it. Continued on 9099-C Unsubstantiated Med techs indicated they were marking medications as refused when the medications had been discontinued, but still showed in the e-MAR. Administrator clarified the procedure with med techs so they no longer document refusals when medications were not refused. Administrator also stated they called the doctor to confirm the medication was discontinued, which it was. Based on the information obtained the allegation is deemed Unsubstantiated at this time. On the allegation: Facility toilet is in disrepair. It was alleged that a toilet was clogged and backed up. Administrator stated staff use the plunger to try to fix the toilet if it is clogged, or they call a plumber. Administrator stated on 5/1/2024, a plumber was at the facility. On 6/4/2024, the plumber was scheduled to come out but did not show up. On 6/5/2024, the plumber snaked the building and did a camera inspection from the clogged toilet through the facility and extended out 17 feet into the front yard toward the street. The camera showed briefs and other objects that had been flushed. The plumber recommended a hydrojet service and this was performed on 6/7/2024. The plumber recommended to monitor the situation and see if it is resolved, otherwise they can do a camera inspection all the way to the street. Administrator also said when doing rounds they will encourage residents to use the restroom at the that time to ensure they have some level of supervision, even if they do not require hands on assistance. Based on the information obtained the allegation is deemed Unsubstantiated at this time. On the allegation: Facility is dirty. LPA toured the facility with administrator. LPA did not observe any dirty areas. Administrator stated overnight staff also clean the facility and disinfect frequently touched surfaces. Based on the information obtained the allegation is deemed Unsubstantiated at this time. On the allegation: Staff engaged in a verbal altercation in presence of residents. It was alleged that two staff argued in front of residents. Administrator stated their new protocol is for staff to update the end of shift report indicating if showers were done for residents. Administrator stated a med tech asked a caregiver about the showers, and the med tech laughed at the caregiver. The med tech asked again, and again the caregiver laughed. Continued on 9099-C The med tech called the administrator to notify them, and the med tech talked about sending the caregiver home. Then another staff stated they did not want the caregiver sent home, and it was noted this staff can have a higher pitched tone of voice. When administrator arrived at the facility, a resident asked if the caregiver was in trouble, because that caregiver is his favorite. Administrator counselled both staff and discussed being respectful, not having disagreements in the common area, and always putting the residents first. Administrator also counselled the other staff on de-escalation techniques and maintaining an appropriate tone. Residents interviewed indicated they liked living at the facility, were treated well by staff, and staff were helpful. Residents stated they have never observed staff argue in front of residents. Based on the information obtained the allegation is deemed Unsubstantiated at this time. Exit interview, report given.the state’s words, verbatim · CDSS document, Jun 11, 2024 · control 29-AS-20240604085405

Allegation investigated: Facility did not give a refund to a prospective residents after deciding not to move in.

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Esmerlda Perez, Medical Technician and explained the purpose of the visit. During the investigation, LPA Olson conducted the initial visit on 6/29/23, and interviewed staff and residents from 2:20pm to 4:45pm. LPA also obtained relevant documentation. On the allegation: Facility did not give a refund to a prospective residents after deciding not to move in. It was alleged that two residents had planned to move in and paid a pre- admission fee. Continued on 9099-C Substantiated However, the residents’ pre-admission fees were not refunded despite never moving in and not signing an admission agreement. Residents’ responsible party indicated they contacted the facility in May 2022, and communicated with Administrator Miriam Santiago and Regional Director Brittnee Kreymer-Austin. They were informed the facility had two rooms available, but insisted they needed to apply immediately, including paying a community fee and base cost as of May 31, 2022. Responsible party paid by credit card to hold the rooms and received the receipt by email. Resident 1 (R1) paid $3776.10 on 5/13/22 and Resident 2 (R2) paid $1726.10 on 5/12/22. The two residents never moved in, and one passed away in June 2022. Responsible party contacted Administrator and Regional Director by phone and email to state the remaining resident would not move in. Responsible party stated the June 2022 fees were abated and they were released from the rooms July going forward; however, the community (pre-admission) fee was never refunded. Administrator Santiago was interviewed on 6/29/23. Administrator indicated she personally did not take the payment for the pre-admission fee. She stated she would request they send out a refund. On 5/30/2024, facility manager confirmed the community fees for R1 and R2 should have been refunded, but they were not. Facility manager was working with their accounting department to get the refund issued. Based on the information obtained, the allegation Facility did not give a refund to a prospective residents after deciding not to move in is Substantiated at this time. Exit interview conducted, deficiency cited on 9099-D, copy of report given, appeal rights given.the state’s words, verbatim · CDSS document, Jun 3, 2024 · control 29-AS-20230628132443

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(5)(E)(1)(a) · Plan of correction due date: Jun 11, 2024

Admission Agreements. A 100 percent refund of a preadmission fee shall be provided…if: The applicant decides not to enter the facility…This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when a refund was not issued to prospective residents, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 3, 2024

Plan of correction: Facility manager is working with accounting department to issue the refund. Facility manager will provide proof the refund was issued to CCL by June 11, 2024.

Allegation investigated: Facility doesn’t have an administrator. Staff are not providing adequate care and supervision.

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Cynthia Garcia and explained the purpose of the visit. During the investigation, LPA Kontilis conducted the initial visit on 12/18/23, and obtained relevant documentation. LPA conducted interviews with responsible parties on 12/13/2023, 12/15/23, 1/29/24, and 2/27/24. On the allegation: Facility doesn’t have an administrator. It was alleged the facility does not have a certified administrator. LPA reviewed facility records. On 10/11/2023, CCL received documents to name Regional Director of Operations Tierre Thorton as Administrator of the facility. Continued on 9099-C Substantiated A permanent administrator (Staff 1) was in the process of renewing their certificate, but would be assist in managing the facility before being officially named AdministratorThe previous administrator resigned on or about 7/12/2023. Staff 1 was disassociated from the facility on 12/18/2023. On April 29, 2024, Regional Director of Operations informed CCL they were leaving their position and another interim staff would oversee the Administrative role. CCL requested documentation for the certified Administrator associated with this facility. Multiple responsible parties interviewed confirmed there had been no permanent Administrator for the facility from December 2023 to February 2024, at time of interview. From 7/12/2023 to 10/11/2023, and 12/18/2023 to present, the facility did not have a Certified Administrator on record with CCL. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Staff are not providing adequate care and supervision. It was alleged that staff were not providing adequate supervision to the residents in care. LPA reviewed incident reports received from the facility. On 1/10/2024 at 1pm, Resident 2 (R2) was observed to exit the front gate when a visitor entered the gate. Staff went to redirect the resident back into the facility. On 2/2/2024 at 3pm, staff received a call from the police that R2 was in their care, as they found R2 at a bus stop. Staff conducted a search to ensure no other residents were missing. The incident reports states to prevent future occurrences, staff had an in-service training on resident safety. It also states in the future staff will escort visitors to the front gate to ensure residents do not follow visitors out. Staff did not know R2 had left the facility until the police called. Based on the evidence obtained, the allegation is deemed Substantiated at this time. Exit interview conducted, copy of report given.the state’s words, verbatim · CDSS document, May 6, 2024 · control 29-AS-20231212163454

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: May 7, 2024

87405(a) Administrator Qualifications and Duties. All facilities shall have a qualified and currently certified administrator. This requirement was not met as evidenced by: Based on interview and record review, the Licensee did not comply with the regulation above when facility has not had certified administrator for months, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 6, 2024

Plan of correction: Licensee will provide documents for CCL to update the Certified Administrator on record assigned to manage and oversee this facility by 5/7/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 7, 2024

Personal Rights…Residents…have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interview and record review, the Licensee did not comply with the regulation above when therethe state’s words, verbatim · CDSS document, May 6, 2024

Plan of correction: Community Manager will provide proof of adequate staffing coverage by 5/7/2024. Community Manager provided proof of inservice training, POC cleared. was insufficient supervision that allowed R2 to elope, which posed an immediate health and safety risk to residents in care.

Allegation investigated: Facility staff did not follow infection control procedures. Facility did not provide residents basic supplies. Facility is not clean. Facility is in disrepair.

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with ______ and explained the purpose of the visit. During the investigation, LPA Kontilis conducted an initial visit on 9/11/2023, toured the facility, interviewed staff from 10:40am to 4:00pm, and obtained documents. LPA conducted additional visits on 9/12/2023 from 12:30pm to 6:30pm and 9/18/2023 from 10:55am to 11:40am. Continued on 9099-C Substantiated On the allegation: Facility staff did not follow infection control procedures. It was alleged that during a COVID-19 outbreak, the facility’s cleaning supplies were locked up and inaccessible to staff. Therefore staff could not properly disinfect and following infection control procedures. Staff interviewed stated over Labor Day weekend, they were unable to access the cleaning supplies in the laundry room and therefore could not properly disinfect. Based on the evidence obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility did not provide residents basic supplies. It was alleged that the key to the laundry room was lost, and therefore staff did not have access to cleaning supplies, laundry facilities, towels or toilet paper. Multiple staff interviewed confirmed over Labor Day weekend, they did not have the key to the laundry room and could not access it. Staff confirmed they did not have access to towels, toiletries, toilet paper, tissues, or cleaning supplies. Staff stated they reported the lack of access to the Memory Care Director when they came on shift and realized the keys were missing. Staff confirmed a visitor brought toilet paper in for the facility. Visitor interviewed stated they brought in one roll of toilet paper for a resident on 9/2/23 and on 9/3/23 brought in a 48-roll pack of toilet paper for all residents. LPA reviewed a locksmith invoice dated 9/5/23. The invoice indicates a mobile locksmith call and new knobset was installed. Based on the evidence obtained, the allegation is deemed Substantiated at this time. On the allegations: Facility is not clean and Facility is in disrepair. It was alleged that a resident’s toilet was clogged for at least four days, and a resident’s toilet was dirty for at least a week with feces present on it. Visitors were interviewed, who stated R1’s toilet was clogged with feces over Labor Day weekend. Visitors stated the facility was unable to get a plumber to fix it until the Tuesday after the holiday. Staff interviewed confirmed the facility had plumbing issues prior to Labor Day weekend and a plumber had already visited the facility. The plumber fixed the plumbing in Room 1, but then later multiple other rooms backed up. Staff stated the plumber came back two to three times to the facility to fix it. Staff stated the facility has a chronic ongoing issue with the plumbing, possibly due to residents putting items or wipes down the toilets. Continued on 9099-C LPA reviewed a plumbing invoice dated Thursday 8/31/23 to fix Room 25, which corroborates that a plumber started addressing the issues prior to Labor Day weekend. Visitors interviewed indicated one resident’s room has a broken heater, and the ceiling has water damage due to a previous leak. LPA during walk thru on 5/6/24 observed water damage to ceiling is still present and it was requested that proof of heater functioning be provided. Staff stated the laundry room wasn’t locking for approximately one month, and the medication room door does not securely lock. During the tour, LPA Kontilis observed the medication room handle, and staff demonstrated the door does not stay locked unless the handle is held up when closing it. During the tour, LPA Kontilis also observed a broken doorknob in Room 4. The door handle inside the room fell off when pulling the door closed, which could pose a danger to residents. During walk thru on 5/6/24 LPA found that multiple keys have been obtained and other work around for possible lock outs have been planned as well as there was no loose door handles noted at this time. Based on the evidence obtained, the allegation is deemed Substantiated at this time. Exit interview conducted, copy of report given.the state’s words, verbatim · CDSS document, May 6, 2024 · control 29-AS-20230905123221

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(b)(1) · Plan of correction due date: May 7, 2024

Infection Control Requirements…Staff…shall be required to perform enhanced environmental cleaning and disinfection to maintain a safe and sanitary environment... This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above when disinfectants and cleaning supplies were not available during a COVID outbreak,the state’s words, verbatim · CDSS document, May 6, 2024

Plan of correction: Facility provided locksmith invoice showing lock was repaired/replaced. POC cleared during visit. which posed an immediate health and safety risk to residents in care.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(a)(3) · Plan of correction due date: May 7, 2024

Personal Accommodations and Services. Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section when the facility could not access toilet paper, towels, hygiene or cleaning products, which posed an immediately healththe state’s words, verbatim · CDSS document, May 6, 2024

Plan of correction: Executive director showed LPA that multiple keys are availiable. POC cleared during visit. and safety risk to residents in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 13, 2024

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on interviews and observations, the licensee did not comply with the section when the facility was not clean or in good repair, which poses potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 6, 2024

Plan of correction: Executive director will provide written proof that the heater and ceiling have been fixed in room 16.

Allegation investigated: Resident sustained injuries while in care

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Cynthia Garcia and explained the purpose of the visit. During the investigation, LPA Olson conducted the initial visit on 6/29/23, and interviewed staff and residents from 2:20pm to 4:45pm. LPA also obtained relevant documentation. On the allegation: Resident sustained injury while in care. It was alleged that on 6/20/2023, Resident 1 (R1) was observed to have bruises on their hand/arm. It was alleged that staff indicated R1 sustained the injury while being “violent” towards staff. It was also alleged that the Administrator at the time indicated the injury was the result of a fall. Continued on 9099-C. Unsubstantiated LPA interviewed R1, who indicated that they received the bruise from falling and both their hands hit their chest. R1 indicated staff helped them and had never hurt them. R1 indicated they liked the facility and received “great care.” R1 also stated they had a scratch from a tiger on their hand. LPA interviewed staff, who indicated R1 sometimes has aggressive behaviors due to their dementia diagnosis. Multiple staff indicated R1 has sustained bruises on their arm from hitting it on doors or gates. LPA reviewed documents including an internal incident report dated 6/19/2023 at 11:30am-12pm. The report states R1 was agitated pushing another resident’s wheelchair and became aggressive when staff intervened, trying to punch and push them. According to the documentation, R1 sustained a skin tear on their right hand. LPA observed photos of the resident’s skin tear from 6/23/24, which appeared to also have bruising. The documentation also indicates the incident and skin tear were reported to their doctor and responsible party. Based on the evidence obtained, there was insufficient evidence to prove R1 sustained an injury as a result of staff neglect or abuse. Therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of report given.the state’s words, verbatim · CDSS document, May 6, 2024 · control 29-AS-20230623160720

Allegation investigated: Staff do not ensure residents receive mail correspondence in a timely manner

On 03/06/2024, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility above to conduct a Subsequent Complaint Investigation Visit and Deliver Final Findings. LPA met with Business Office Director Cynthia Garcia and Medication Technician Anais Ochoa and explained the purpose of the visit. On the allegation: Staff do not ensure residents receive mail correspondence in a timely manner. It is alleged that from 02/16/2024 through 02/20/2024, postal mail has been unable to be retrieved for Resident #1 (R1). The allegation states that the Responsible Party for R1 has attempted each day to get the mail with either no staff available or Staff not having a key to the mailbox/Staff Office where a mailbox key is kept. It is also alleged that none of the residents have been receiving the mail since 02/16/2024. On 02/26/2024, LPA requested documents pertaining to the investigation, conducted observations of the pertinent areas of the facility, and interviewed both Residents and Staff members of the facility. Contd 9099-C Unsubstantiated LPA observed the mail areas in separate sections of the facility and found the mail to be distributed to residents up to the date of the initial visit by LPA. The facility has a main outdoor mail drop box/mailbox for residents of the facility in the front outdoor area of the facility adjacent to the vehicle entrance gate. Additionally, the facility maintains a separate mail drop box/mailbox attached to the Office of the Business Director of the Facility, which is located directly adjacent to the main front door entrance of the facility. LPA toured the facility and observed all areas where mail for residents is placed, distributed, collected, etc. All mail items for residents observed by LPA were of good quality; there was no observed destroyed or tampered mail. There was no indication of any late/undelivered mail, and all resident mail items/letters were observed to be stored properly. During the LPA's touring of the mailbox areas, policies and procedures on the distribution of mail were observed and mail items had the dates that they were received by the facility labeled on the mail. Both mailboxes that received and stored resident correspondence were locked at the time of LPA observation and needed to be unlocked by Staff member with key. There were no observable deficiencies in the mail correspondence to residents at the facility. On 02/26/2024, LPA interviewed residents and staff about the timeliness of mail correspondence to residents at the facility. LPA interviewed Staff member #1 (S1), who stated that there are only a limited number of Staff members with keys into the mail boxes on site in the facility, but that there is at least one or two Staff members with a mail key on any shift at the facility, AM or PM. S1 stated to LPA that there are also mailbox keys on the same keychains and the keys used to lock Centrally Stored Medication to be inaccessible to residents. S1 showed LPA the process of retrieving the mail from both mailboxes on site. LPA was shown the main large, locked mailbox/drop box at the entrance of the facility outside of the vehicle entrance gate, at the locked door/electronic gate to enter the facility. The second mailbox is smaller and located right outside the door of the Business Office Director, which holds more sensitive documents and documents from resident visitations/relatives/family members. S1 informed LPA that due to a number of residents in the facility having psychological impairments such as Dementia, there are times when mail is received for these residents that a Power of Attorney (POA) or responsible party for the resident needs to be informed of the mail prior to handing it off to a resident. S1 stated many residents with Alzheimer’s/Dementia or related conditions tend to lose their mail and/or misplace it. S1 stated to LPA that the mail is checked daily by facility management/administrator or by the Med Tech(s) on duty on either an A.M. shift or a P.M. shift. S1 stated that they did ensure residents receive mail correspondence in a timely manner, and that sometimes a third party needs to be involved due to the mental capacity of certain residents (POA/Responsible Party). Continued on 9099-C On 02/26/2024, LPA interviewed multiple residents who indicated that they received their mail on time, and had no issues with postal mail correspondence at the facility. Some residents interviewed stated that the mail correspondence has improved during their time in the facility, and that they have no current complaints. LPA was provided with pertinent documentation by the facility including a Facility Program of Care, Program Description & Brochure, Admission Agreement, Rules of Discipline, Theft & Loss Policy, Statement of Residents’ Personal Rights, Employee listing report with contact information, and Resident roster. The current Resident Admission Agreement for the facility indicates that each resident will have Personal Rights consistent with California law, including the resident personal right to mail and to receive unopened correspondence in a prompt manner. In addition to LPA observations, interviews, and record review of the facility on 02/26/2024 for the initial complaint investigation visit, LPA interviewed the Responsible Party for R1 on 02/26/2024. LPA asked the Responsible Party for R1 about any suspected Financial Abuse of R1 relating to the Financial Documents for R1 sent to the facility mailing address including a bank card for R1 which were never received. LPA asked RP if they checked the status of R1’s account to make sure any financial information had not been stolen/misused and RP stated that there were no signs of R1's money being used or any signs of financial abuse. RP is the Power of Attorney (POA) for R1 and recently changed the address of the resident from the facility to a P.O. Box so RP is sure the mail will be received. RP stated that the facility has never admitted to receiving any of the mail for R1, and all Staff members interviewed by LPA on 02/26/2024 corroborated this statement. No Staff member admitted to receiving any postal mail for R1 that was described by RP. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Mar 6, 2024 · control 29-AS-20240220152049

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management - Annual Continuation visit to the facility above. LPA met with Tierre Thornton, Regional Director of Operations and explained the purpose of the visit. LPA conducted a tour of the facility and reviewed staff records for background checks. LPA will return at a later date to continue the inspection. Due to technical issues, LPA issued the report via email at the time of the visit.the state’s words, verbatim · CDSS document, Feb 13, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Required Inspection of the facility. At the time of arrival, there were two (2) staff on duty and fourteen (14) residents in care. LPA met with Cynthia Garcia, Business Office Director (BOD), and explained the purpose of the visit. Entrance interview conducted: The facility is a one-story Residential Care Facility for the Elderly (RCFE) with a capacity of thirty-six (36) residents. The facility is a memory care facility for residents with a dementia diagnosis. The facility has a fire clearance for thirty-six (36) bedridden residents and a hospice waiver for ten (10) residents. Currently, there are no residents on hospice and no bedridden residents residing in the facility. LPA and BOD toured the facility to assess the physical environment and accommodations. The following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. Upon entry, there is a gate that requires a code to enter the premises and a phone number posted to the facility for those who do not have a code. Entering through the gate, is a large walkway and driveway leading up to a large front patio with seating areas including patio chairs, tables with umbrellas, couches, and mini-couches. Entering past the patio area, the administrator’s office is located on the west side of the building. Staff files and other confidential information is kept in the administrator’s office. Entering into the main area of the facility is the dining area/common area on the east side of the room. Socializing, meals, and activities are held in the dining/common area. The kitchen is located at the back of the dining/common area and is inaccessible to residents in care. LPA observed seven (7) days of non-perishable food items and two (2) days of perishable food items. LPA also observed an ample amount of emergency and frozen foods. The medication room is located on the west side of the facility just past the main entry. The medication room requires a code to enter the room. Residents’ medications, residents’ files, and first aid kit are kept in the medication room. The medication room overlooks the common area. <Please continue to 809-C, Pg 2 Past the medication room is a hallway that leads to residents’ rooms, bathrooms, and shower rooms. There are twenty-four bedrooms and three (3) full showers located off the hallways. Each bedroom is equipped with a sink in the bedroom and a toilet room. The bedrooms were inspected and found to have sufficient bedding, lighting, and storage for each resident in care. Each room has individual temperature control to be adjusted to the resident's comfort level. The three shower rooms are set up for residents to be taken into the shower room for showers while staying in their wheelchair. The shower rooms have non-slip flooring and grab bars for the residents and there are shower chairs the residents can utilize. The Facility maintains five (5) working carbon monoxide detectors and approximately eight (8) smoke detectors all in good working order. From approximately 2:55 pm to 3:05 pm, LPA and BOD observed foul odors in the bathrooms of Bedrooms 4 and 5 and the Bedrooms 9 and 16. From approximately 3:15 pm to 3:17 pm, LPA and BOD observed five fire extinguishers were last serviced on 1/5/2023. Due to time restraints, LPA will return at a later date to continue the annual inspection. Exit interview conducted. The following deficiencies were observed (see LIC809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Civil penalty issued at the time of the visit. Failure to correct the deficiencies by the correction due date may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.the state’s words, verbatim · CDSS document, Jan 30, 2024

Allegation investigated: Due to a lack of staffing, staff are not answering the facility phone. Staff did not notify authorized representative of incident with resident.

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced subsequent visit to address the above-stated allegations. LPA met with Anais Ochoa, Medication Technician and explained the purpose of the visit. At the time of arrival, there were fourteen residents in care with two staff on duty. On the allegation, due to lack of staffing, staff are not answering the facility telephone: Reporting Party (RP) stated RP has placed numerous unanswered calls to the facility’s main line and has not been able to leave a message or speak with facility representatives. On 8/23/2023 one call was placed to the facility unanswered. On 8/24/2023, four calls were made to the facility. One call was answered and RP had a conversation with a facility representative. However, after the conversation, RP called back two more times, but the calls were not answered and no voicemail option was available. On 8/25/2023, RP stated two unanswered calls were placed to the facility. Also, on 8/25/2023, RP stated R1’s Physician was trying to fax a prescription to the facility, but the Physician stated the facility's fax machine was not properly functioning. RP stated the calls to the facility and the fax from R1’s Physician were a dire medical concern regarding R1. Please continue to 9099-C, Pg 2. Substantiated During today’s visit, interviews conducted revealed that staff are sometimes unable to answer the phone because they are assisting residents with brief changes, showers, medication distribution, and other basic services. Staff 1 (S1) stated when the calls go to voicemail, the staff (caregivers, medication technicians, etc) on duty do not have access to retrieve the voicemail messages. S1 further stated when S1 takes a call and cannot provide information, the caller’s name and phone number are taken in a message book then S1 gives it to a “corporate person” when they come to the facility. During today’s visit, LPA observed the Business Office Director and the Regional Director of Operations were not available at the facility. Staff stated the Business Office Director was at the facility for approximately three hours on Monday, 1/22/2024. Staff further stated the Regional Director of Operations was at the facility for approximately one hour one day last week, possibly Tuesday, 1/16/2024 or Wednesday, 1/17/2024. Based on interviews conducted, records reviewed, and observations made, the allegation that due to lack of staffing, the facility staff are not answering the facility telephone is Substantiated at this time. On the allegation, staff did not notify authorized representative of an incident with a resident, Reporting Party (RP) stated RP learned that Resident 1 (R1) was taken to the hospital emergency room on 12/4/2023 when RP received an invoice from the medical emergency agency about three weeks after the emergency transport. During today’s visit, LPA obtained medical discharge papers and care notes indicating R1 was sent to the hospital via a call to 9-1-1. At approximately 2:34 pm, Staff 2 (S2) stated on 12/4/2023, R1 was sent to the hospital emergency room the evening of 12/4/2023. S2 further stated R1 returned from the hospital emergency room that same evening. LPA reviewed LIC624 Serious Illness/Serious Injury Reports submitted by the facility to Community Care Licensing Division (CCLD) and determined that CCLD did not receive LIC624, Serious Illness/Injury Report notifying CCLD of R1’s hospital visit. At the time of the visit, no record of an incident report was available reporting R1’s emergency room visit to R1’s responsible parties or to CCLD. Based on interviews conducted and records reviewed, the allegation that facility staff did not notify an authorized representative of an incident with a resident is Substantiated at this time. The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.the state’s words, verbatim · CDSS document, Jan 24, 2024 · control 29-AS-20240117104513

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jan 25, 2024

Type A 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…. This requirement is not met as evidenced by: Based on interviews, record review, and observation, the licensee did not comply in the section cited above as facility staff were unable to answer telephone calls from R1's responsible party on 8/23/2023, 8/24/2023, and 8/25/2023 which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 24, 2024

Plan of correction: Licensee agrees to provide a written plan to CCLD as to how the facility will be diligent in answering telephone calls and responding to responsible parties through telephone communication. Written plan will be submitted to LPA via email no later than 4:00 pm on 1/25/2024.

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

87211(a)(1) Each licensee shall furnish to the licensing agency such reports as the Department may require,... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified... This requirement is not met as evidenced by: Based on record review, observation, and interviews conducted, the licensee did not comply in the section cited above as the facility staff did not notify R1's responsible party of a hospital visit; nor did the facility notify CCLD of the hospital visit.the state’s words, verbatim · CDSS document, Jan 24, 2024

Plan of correction: Licensee agrees to provide a written plan to CCLD as to how the facility will be diligent in reporting incidents of serious illness/serious innury to responsible parties and CCLD. Written plan will be submitted to LPA via email no later than 4:00 pm on 1/25/2024.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced case management visit to follow up on an immediate exclusion order issued 11/16/2023 for Staff 1 (S1). Marco Quintanar, Program Manager, Long Term Care Ombudsman (LTCO), Santa Barbara County accompanied LPA in the visit. LPA and LTCO met with Allie Sotelo, Medication Technician and explained the purpose of the visit. Cynthia Garcia, Business Office Manager arrived at approximately 11:43 am. Prior to assistance, Business Office Manager completed the process to associate self to the facility. At approximately 8:17 am, LPA reviewed the facility’s fingerprint clearance roster and observed S1 was still associated to this facility. Cynthia Garcia, Business Office Manager disassociated S1 from their fingerprint roster during the visit. Regional Director of Operations Tierre Thornton stated S1 had not been physically present in the facility since 12/6/2023, the date when Tierre Thorton stated the exclusion order was received. LPA interviewed other staff in the facility who confirmed S1 had not been present recently. LPA reminded Garcia that any further presence of S1 in the facility or interacting with clients violates the exclusion order and the facility could be subject to deficiencies and civil penalties if they do not abide by the order. Exit interview conducted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Dec 18, 2023