Santa Maria Terrace

Allegation investigated: Facility staff did not meet resident's needs Resident does not have a call button accessible

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Vanessa Vasquez, Designee, and explained the purpose of the visit. During the initial visit on 11/19/25 LPA Rankin conducted interviews and collected relevant documentation. During the investigation LPA reviewed facility records, requested and received Home Health Agency records and notes, interviewed staff, family and reporting party. On the allegation: Facility staff did not meet resident's needs It was alleged that Resident #1 (R1) is soiled in urine during visits done by the outside agencies and that staff state they provide the level of care that R1 has paid for. Continued on 9099-C Unsubstantiated On 11/17/25 at 10:52 am, LPA conducted a telephone interview with the Reporting Party (RP). RP stated that during their visits, R1 has been soiled, and RP reported that documentation from the physical therapist and other nursing staff also indicates that R1 was found soiled on multiple occasions. RP additionally stated that during their visits, R1’s television was not working and that R1’s bedroom appeared “thrashed.” On 11/17/25 at 2:50 pm via phone call, LPA interviewed Family #1 (F1) who stated that they believe R1 is choosing to be in a diaper, is very agitated, and refuses care such as changing, and showers. R1 refuses to go to doctor appointments, stated that a doctor saw R1 within the last week and agreed R1 should be on hospice, but R1 is refusing. F1 stated there is limited money, so they can only afford minimum care. F1 stated that the “facility is trying, but [R1] is being difficult.” On 11/19/25 during initial visit LPA collected documentation of communication from the facility to the doctor, tracking records where staff note care attempted and results, medication lists, and Outside Provider Notes. LPA was provided faxed communication from the facility to the doctor between 10/21/25 to 10/26/25 where the facility communicates R1’s increased anxiety, increased pain, declining to eat normally, declining staff assistance with Activities of Daily Living (ADLs), becoming incontinent, refusing assistance with changing their clothes and bedding and isolating themselves. Notes regarding facilities attempt to provide care include documented services and attempts of services for: showering which states from 10/1/25 to 11/12/25 resident refused showers 10 times. Documentation of resident refusing housekeeping cleaning 2 times between 9/25/25 to 11/6/25. Documentation of incontinent care 3 times a day from 10/21/25 to 11/10/25 show resident refused care 10 times over a 20-day period. On 11/17/25 LPA emailed a request for records from the Home Health agency. On 11/19/25 records were provided to Community Care Licensing which included “Visit Note Reports” dated from 10/6/25 to 11/13/25. Home health visit notes reflect ongoing concerns regarding R1’s environment, mood, personal care, and functional decline. Documentation shows 3 out of 12 visits with notes where R1 was found in a soiled condition or in a malodorous room, supporting the allegation. However, the same documentation also consistently indicates that R1 frequently refused care, resisted interventions, and declined assistance from both home health staff and facility caregivers. Page 2 Continued on 9099-C R1 was repeatedly described as irritable, withdrawn, angry, and “actively resisting care.” Notes indicate R1 refused physical therapy, declined assistance with toileting and mobility, and resisted recommended medical evaluation. Staff consistently reported R1’s isolation, poor engagement, and unwillingness to leave the room. Collectively, these records and interviews show that while R1 was at times found soiled or in an unclean environment, these conditions were significantly influenced by R1’s right to refuse care and interventions. The documentation also reflects ongoing efforts by facility and home health staff to address R1’s care needs within the limitations of R1’s cooperation and authorized care level. On 5/28/26, LPA conducted interviews with facility staff via phone and reviewed R1’s current Service Plan. Staff reported that R1 is currently thriving and is ambulating with the assistance of a walker. The review of R1’s plan of care indicates that R1’s Activities of Daily Living (ADL) assistance level was reduced as of 3/12/26, and that R1 is now attending activities and coming down to meals regularly. When asked about the changes in R1’s functioning, staff stated that R1 was admitted to hospice on 11/22/25. During hospice services, R1 participated in physical therapy, and hospice staff were able to stabilize R1’s pain with appropriate medication and had quicker access to a physician who adjusted medications as needed. Documentation provided and staff reported that R1 graduated from hospice on 2/19/26 due to decreased decline. Based on interviews, facility documentation, home health notes, and record review, R1’s frequent refusal of care, medical appointments, and ADL assistance contributed significantly to the concerns reported. Therefore the allegation is UNSUBSTANTIATED. On the allegation: Resident does not have a call button accessible It was alleged during visits from outside agencies R1 no longer had a call light available for use in their room. Page 3 Continued on 9099-C On 11/17/25 at 10:52am via phone call, LPA interviewed reporting party (RP). RP stated that the call button disappeared. That R1 is unable to get out of bed. RP claims that R1 went weeks without a call button and was requiring the family to pay for a new one and that the family was refusing to pay. LPA reviewed and collected invoices for 9/1/25, 10/1/25 and 11/1/25 of R1’s care and saw no charges related to call buttons or unknown fees. LPA reviewed Home Health Agency notes from 10/5/25 to 11/17/25 and found one note on 10/6/25 that stated R1 “did not have call button…” and one on 11/11/25 stating “Patient has a call button bed side” “Safety-Patient has a call light button and is checked on by staff 2 times minimum a day.” All other dates of services were reviewed and the area asking the provider to review “Emergency Button Needs” did not address any other instance of missing call buttons. On 11/17/25 LPA interviewed F1 and asked does R1 have a call button and were they ever without one? F1 stated R1 “has had one the whole time.” Interview with Wellness Director on 11/19/25, stated F1 called at one point to let the facility know that Home Health had stated that R1 did not have a call button. Wellness Director stated she created a new button in their system and went upstairs to give R1 the button and found the other call button in the resident’s bathroom. Based on interviews, and record review. At this time there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, copy of report given.the state’s words, verbatim · CDSS document, May 29, 2026 · control 29-AS-20251113130026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melisa Rankin arrived at 9:13 a.m. to conduct a 1-year required annual visit. LPA met with Joanna Enriquez, Administrator. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: LPA toured 5 resident rooms and observed that rooms were tidy, the lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secure grab bars are present. The showers have non-skid flooring. The pathways are clear of any obstructions. Facility is well lit inside for safety. Disinfectants and cleaning solutions are inaccessible to residents in care and locked in kitchen closet and housekeeping room. The facility has sufficient space inside and outside for activities and visiting. The facility has telephone and internet service for resident use. The fire extinguishers were last charged and inspected on 10/14/25. The facility has carbon monoxide detectors throughout the facility, and a sprinkler system. Sprinkler system was certified tested on 5/19/25. Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 140. The fire clearance is granted for 140 non-ambulatory of which 10 may be bedridden. Hospice waiver approved for 40 residents. The facility currently has 96 residents. There are currently 4 residents on hospice. Certificate of liability expires 10/1/26. (Continued on 809-C) Staffing, Personnel Records & Training: The facility currently employs 48 full-time staff and 1 administrator. Files reviewed had current 1st Aid/CPR, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Administrator Certificate expires 6/23/26. Staff have annual training completed for required topic for 2025. Resident Records & Incident Reports: The facility keeps separate files on each resident confidential. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians reports, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms. All forms were legible. Activities: During visit, LPA heard singing, games, a bible study, and toured garden where residents were walking, visiting on the patio, and enjoying pets in the community. Garden area is large, with multiple paths, shaded areas, and plants. It was clean, well maintained, and gated. Copies of the last 5 months’ activity calendars were provided to LPA. Activities noted for date of LPA visit, matched activities that occurred. Food Service: The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower, logs of temperature checks were reviewed. All food is covered, stored, and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies. Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents’ medications, no labels were altered, no medications were expired, and all medications were kept in their original containers. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts monthly disaster drill/training, last one was conducted on 10/21/25. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. During recent fire event facility pre-called family to prepare for possible evacuation. Exit interview conducted, no deficiencies issues and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Oct 22, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not prevent a resident from sustaining multiple falls. Staff administered a medication that was not prescribed to a resident in care.

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with Wellness Director and Administrator and explained the purpose of the visit. During the investigation, LPA conducted an initial visit on 7/21/2025 from 11:44 am to 2:30pm, where LPA conducted interviews with administrator, staff, wellness director, and obtained relevant documents. Interviews with reporting party were conducted on 7/21/25, pictures of Resident 1 [R1] following incidents were provided. Additional documentation was requested from the facility on 7/25/25 and provided to the LPA by the facility on 7/25/25 and 7/28/25. Interviews with the Nurse Practitioner (NP) were done on 7/25/25 at 3:20 pm. Tour of R1’s room was done on initial visit on 7/21/25. Continue on 9099-C Unsubstantiated On the allegation: Staff did not prevent a resident from sustaining multiple falls. It was alleged that R1 had a fall on 06/27/25 in which R1 hurt their knee, alleged that within twelve hours of the first fall the resident got up to use the bathroom and fell and hit [their] head and was transported to the hospital. Reporting party stated that R1 lost 2 pints of blood. Records indicate there were 3 incidents, all unwitnessed, all occurred in residents’ room within a 24-hour timeframe, 2 on 6/27/25 and 1 on 6/28/25. On 6/27/25 R1 was found at approximately 7:00 am by medication aid during medication pass, R1 was on the floor in their room. Records state and staff interviews confirmed staff assessed R1 for injuries, initially R1 verbalized no pain or injury, staff got R1 off the floor and immediately observed R1 limping and facility contacted 911, per interview with Wellness Director (WD) first responders assessed R1 and spoke with R1 and R1’s family member (F1). Medical transport was refused after the conversation, and additional medical treatment was not sought by the request of R1 and F1. Records show that at 9:55 am R1 was given a prescription PRN Tramadol for pain. Facility records show NP was notified of incident at 1:06 pm via fax. Facility submitted an incident report to Community Care Licensing (CCL). On 6/27/25 at approximately 1:45 pm staff heard R1 yelling for help, R1 told staff and records state that R1 was trying to open their door and fell. Physical Therapy referral requested. WD stated the fall was due to R1 not having shoes on. R1 was assessed, no injuries present. Facility records show NP was notified of the incident at 11:25 pm via fax. On 6/28/25 R1 was found during the medication pass at approximately 5:30 am. Interviews and records state medication aid walked in and observed R1 on the floor and noted a “head injury and resident near [their] bed on the floor.” Facility called 911 and stayed by R1. Records state, “resident unable to give description” of what had happened and that “Resident appeared disoriented.” The incident resulted in unknown head injury, with blood loss. Review of R1 medication records shows they were on a blood thinner. During record review, LPA noted that physician’s order dated 6/2/25 and 6/16/25 for PRN Tramadol stated, “1 tablet orally at bedtime as needed for pain”. During an interview LPA was told that medication was given the morning after the incident and Medication Administration Record (MAR) showed R1 took a PRN tramadol at 9:55 am on 6/27/25. Interview at 3:20 pm on 7/25/25 with NP, LPA inquired why PRN was ordered for “bedtime”. NP stated prescribed “at night, in case the resident gets tired from the medication, and so they don't fall." Continue on 9099-C Record reviewed do not show history of falls, pre-assessment documented by F1 states R1 had a mini stroke in March, but “has not fallen…” Interviews with staff for incidents on 6/27/25 state that R1 was at their normal baseline following both incidents. Staff state R1 is usually a little confused and needs prompting. Record review indicates that the care level assessment and Service Plan Report effective date 4/21/25 for R1 shows that R1 requires cueing throughout the day for orientation, escort and cueing for; meals, activities, moving throughout the facility, that R1 requires frequent checks for toileting, brief changes, medications, reminders for daily activities, transfers in and out of bed, bathing, and grooming in the morning and bedtime. R1 does not have a history of falls prior to entering the facility and has not had falls until the 3 incidents noted above which occurred in a short time frame. Facility followed their protocols, requested emergency services, notified a medical professional, requested PT after a second incident. Based on record review and staff interviews at this time the above allegation was found to be unsubstantiated, there is not a preponderance of the evidence to prove that the alleged violation occurred. On the allegation: Staff administered a medication that was not prescribed to a resident in care. It was alleged medication provided to R1 on 6/27/25 did not belong to the R1. The documented order dated 6/2/25 and renewed order on 6/17/25 was provided to the LPA upon request, both were signed by the NP and confirmed during interview with NP on 7/25/25. Medication was prescribed, but given at 9:55 am which is not following doctor’s order of “1 tablet orally at bedtime as needed for pain.” LPA conducted a Case Management addressing this medication error. Based on record review and interviews conducted, at this time the above allegation was found to be unsubstantiated, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted. Copy of report provided to facility.the state’s words, verbatim · CDSS document, Aug 5, 2025 · control 29-AS-20250717121638

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Rankin conducted a Case Management - Incident visit to issue deficiencies on a medication error discovered during a complaint visit. LPA met with the Administrator and Wellness Director and explained the purpose of the visit. During record review conducted for a complaint visit on Resident 1 (R1), LPA noted that physician’s orders dated 6/2/25, received 6/16/25 for PRN Tramadol stated, “1 tablet orally at bedtime as needed for pain”. During an interview LPA was told that medication was given the morning after an incident and Medication Administration Record (MAR) showed R1 took a PRN tramadol at 9:55 am on 6/27/25. MAR has the order written as “Give 1 tablet by mouth every 24 hours as needed for Pain DNE 1 tab in 24hrs.” Review of Facility care plan for R1 and Physician Report for R1 notate that R1 needed medication management from the facility Interview at 3:20 pm on 7/25/25 with prescribing Nurse Practitioner, LPA confirmed that the PRN order was ordered for “bedtime”. NP stated prescribed “at night, in case the resident gets tired from the medication, and so they don't fall." Images of medication were provided to LPA which show prescription label of “bedtime” and the order states as noted above that it is 1 tablet at bedtime as needed for pain. Continued on 809-C Based on interviews conducted and record reviews, the facility did not follow physician order when medication was given outside of the prescribed time frame. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency were cited (refer to LIC 809-D). An exit interview was conducted, a copy of the report, and appeal rights were issued.the state’s words, verbatim · CDSS document, Aug 5, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 5, 2025

87465 Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met based on interviews and records reviewed, licensee did not comply with the section cited above when Staff gave R1 a medication at 9:55am, but order and interview with medical professional stated “bedtime”, which posed a potential health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Facility will complete an in-service training with medication staff regarding PRN awareness of possible time frame parameters, and an audit of the electronic Medication Administration Records (eMAR) will be reviewed to ensure the eMAR matches the Orders.

Allegation investigated: Staff are violating residents’ personal rights

On 3/25/25 at 12:52 p.m. Licensing Program Analyst (LPA) Melisa Rankin arrived at the above to conduct a Complaint Investigation Site Visit. LPA met with Administrator Joanna Casillas and Wellness Director Vanessa Vazquez and explained the purpose of the visit. During visit LPA conducted interviews with staff and resident and reviewed and gathered relevant documents. ------------------------------------------------------------------------------------------------------- On allegation staff are violating residents’ personal rights Complaint states the resident is unable to leave the facility unassisted when resident has requested to go to their vehicle, attend events in the community, and go to shopping centers. Unsubstantiated After interviewing resident, the concern has been they wish to leave the facility, in their vehicle and believe they are healthy and capable to do so unassisted. LPA reviewed recent MRI medical record dated 3/10/25 and admitting LIC 602A Physicians Report dated 01/28/25. MRI document stated “Indications: Mild Dementia” and 602A states “Dementia” Diagnosis. Due to the regulations regarding residents with a diagnosis of dementia stating: 87705 Care of Persons with Dementia (e)(3) Facility staff shall attempt to redirect a resident at risk for elopement who may be attempting to leave the facility without violating Section 87468.1, Personal Rights of Residents in All Facilities. (4) Residents who continue to indicate a desire to leave the facility following redirection shall be permitted to do so with staff supervision. LPA interviewed facility staff, and all parties interviewed concur that residents with the dementia diagnosis are first redirected and then told they cannot leave the facility without someone to accompany them. Administrator, when interviewed also stated that when she and other staff have been approached by residents wanting to leave who have the dementia diagnosis, they do not physically restrain the residents, but the front staff, and wrist alerts do notify them of residents leaving and they work to redirect, and then will follow if the resident insists. Currently the facility is following regulations, due to the noted diagnosis of the resident. 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. Copy of report printed and given to Licensee.the state’s words, verbatim · CDSS document, Mar 25, 2025 · control 29-AS-20250320162158

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erika Miller arrived at 10:36 a.m. to conduct a 1-year required annual visit. LPA met with Joanna Enriquez, Administrator. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has at least a 30-day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Physical Plant & Environment Safety: LPA was authorized to enter and inspect facility. LPA toured 10 resident rooms and observed that rooms were tidy, the lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant and cleaning solutions are inaccessible to residents in care and locked in kitchen closet. The facility has sufficient space inside and outside for activities and visiting. The facility has telephone and internet service for resident use. The fire extinguishers were last charged and inspected on 10/20/23. The facility has carbon monoxide detectors and a sprinkler system that were tested 10/3/24 and 5/31/24 respectively. Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 140. The fire clearance is granted for 140 non-ambulatory of which 10 may be bedridden. Hospice waiver approved for 40 residents. The facility currently has 46 non-ambulatory, and 1 bedridden resident. There are currently 3 residents on hospice.. (Continued on 809-C) Staffing: The facility currently employs 49 full time staff and 1 administrator. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Administrator Certificate is currently pending with Community Care Licensing. Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2023 and 2024. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians reports, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms. All forms were legible. Food Service:. The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored, and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies. Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents’ medications, no labels were altered, no medications were expired, and all medications were kept in their original containers. Disaster Preparedness: The current emergency disaster forms were posted. The facility last conducted a quarterly disaster drill/training on 8/27/24. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Exit interview conducted, no deficiencies issues and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Oct 3, 2024

Allegation investigated: Facility staff did not provide medication to resident for pain management

Licensing Program Analyst (LPA) Erika Miller (Miller) conducted an unannounced complaint visit on 10/1/24 to issue final findings on the allegations above. During the investigation, LPA, Miller, toured the facility and interviewed staff on August 16, 2024, from 10:49 a.m. to 1:00 p.m. LPA also obtained and reviewed relevant documents. LPA met with Joanna Enriquez, Administrator and Amy Bowman (Bowman), Wellness Director, to explain the purpose of the visit. On the allegation: Facility staff did not provide medication to resident for pain management. It was alleged by Reporting Party (RP) that on August 8, 2024, they observed that Resident 1(R1) was complaining of pain in her neck, spine, and leg. RP states they advised a Staff and expressed concern for the R1’s pain. It was alleged that the staff did nothing to help R1 with pain management. Bowman stated that the facility does not deny pain medication to residents in pain. Bowman further stated that staff may not provide pain medication, outside the pain management window. (Continued on 9099-C) Unsubstantiated There may also be instances, that staff could ask a resident if they could wait until the next pain medication window. When a resident cannot wait, staff will contact hospice for direction on administering breakthrough pain medication. Facility policy is to review the electronic MAR to ensure an additional dose is permissible. Bowman stated that if a Med Tech is advised that a resident is in pain, they would typically speak to resident and follow policy. On August 8, 2024, newly hired Med Techs were in training and may not have known how to explain pain management procedures and policies. A request for copy of July and August e-MAR was made on 9/20/24 via email. LPA reviewed the MAR for R1 and observed that PRNs for pain were given during the months of July and August 2024. Bowman advised LPA that R1 is to receive Norco 4 times a day routinely as needed. R1 also has a comfort kit consisting of Lorazepam and Morphine to be used at the time of her passing. LPA reviewed physician’s report that states R1 to avoid aspirin and NSAIDS. LPA interviewed R1 about their pain management. R1 stated they were in pain yesterday and the day before they were not. R1 stated, “I’m feeling so lousy”. R1 stated that there are days Staff provide medication for pain and on other days Staff will not provide medication for pain. R1 visibly confused. R1 could not recall if they had eaten that day and made various statements; “I’m ready to leave, I’m hanging, I’m ready to give up, I’m so tired of it now, I’m 96 and I’m at the very end of my rope”. At the time of this report, R1 has passed away. Although, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. LPA interviewed R1 about their experience with staff assistance during meals. R1 was unable to provide any insight into LPA questions. It was alleged staff did not reposition R1 in their bed during mealtime. LPA reviewed R1’s physician’s report and care plan, which indicates R1 is non-ambulatory and has motor impairment and paralysis. LPA observed R1 was able to slightly adjust themselves in bed and from LPA observation it was clear that R1 required additional assistance. Bowman described a separate incident on 8/8/24. S2 entered R2’s bedroom and advised they were not trained and did not know how to change and reposition resident. R2’s daughter was present and notified Bowman of the incident. Bowman stated that this was not the first instance of S2’s failure to perform duties. S2 was terminated effective 8/12/24. Based on the multiple accounts by multiple staff, it is reasonable to believe that a staff member was not repositioning residents and was ultimately terminated. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations are being cited on the attached LIC 9099D. Exit interview conducted, copy of report issued.the state’s words, verbatim · CDSS document, Oct 1, 2024 · control 29-AS-20240809092613

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2 · Plan of correction due date: Oct 1, 2024

Additional Personal Rights of Residents ... in privately operated residential care facilities... shall have... 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.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: Licensee agreed to ensure staff are adequately trained and will continue to conduct 30-day performance reviews to determine if additional training is needed and such training will be completed within a 90-day window.

Allegation investigated: Staff did not dispense resident’s medication according to doctor’s orders. Staff did not ensure resident receives contracted amenities.

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Sanjuana Enriquez, Administrator and Amy Bowman, Designee and explained the purpose of the visit. On the allegation: Staff did not dispense resident’s medication according to doctor’s orders. It was alleged that for two weeks the facility did not administer Resident 1 (R1) pain medication as prescribed which was stated by Family 1 (F1) to be taken every six hours or as needed (PRN). It was also alleged staff have refused to give R1 pain medication when asked. Continued on 9099-C Unsubstantiated F1 states one day R1 went 13 ½ hours between doses and is now having anxiety and agitation due to the pain. Interview conducted on 5/24/24 at 3:45 pm, F1 stated R1 was not getting medication as prescribed, R1 had to “chase” medication aids for medication, R1 is calling panicked about not receiving medication, per F1 there was no one there to give lunch medication on 5/24/24. On 6/3/24 the Designee provided copies of R1’s Medication Administration Records (MARs), May staffing schedule, R1’s Centrally Stored Medication list, which included doctor’s orders, as well as Pallotive care’s updated prescription for Norco and Seroquel. On 6/10/24 LPA requested copies of sign-in sheets, and cross reviewed them with initialed MAR records show there was coverage for all medication pass shifts including 5/24/24. On 6/10/24 LPA reviewed May medication records for R1. Per MAR records, R1 was receiving all medication prescribed at the correct time. The PRN pain medication, per the MAR record shows from 5/4/24 to 5/23/24 R1 had taken the medication with 7 to 15 hour gaps, records show most time frames were over 11 hours apart. R1’s pattern shows that a 13-hour delay in this medication is consistent with R1’s history. On 5/24/24 this pain management medication was changed to a standing 6-hour distribution per updated doctor’s order. A medication review was conducted by LPA at 12:30 pm with Designee and R1’s medications show that it has been followed as prescribed since 5/24/24. Based on interviews, and documentation obtained, there is not enough evidence to prove the allegation of, “Staff did not dispense resident’s medication according to doctor’s orders” and it is unsubstantiated at this time. Continued on 9099-C On the allegation: Staff did not ensure resident receives contracted amenities. It was alleged that on 5/22/2024, the facility updated either the wi-fi or cable services and since then, per F1, R1 has not been able to watch their personal television (TV) in their room because it is not a smart TV and is not compatible with the new system. F1 states staff told them they will eventually give R1 a compatible TV but not the same size as R1’s current TV. F1 states staff did not advise them of the service change so F1 could make sure that R1 continued to have a working TV available. Interview with F1 on 5/24/24 at 3:45 pm, they stated R1 was without TV service, F1 stated they had told R1 about the change in services but had not informed F1. F1 said if they would have known ahead of time, they could have provided a new TV. Interview conducted on 6/3/24 with R1 and F1, R1 stated their TV was still not working. Per interview with Administrator, a notice of TV service interruption was handed out to resident’s inboxes and posted on 5/20/24 that services would be down on 5/22/24 through 5/24/24. When services were restored that is when it was discovered some TVs would not be compatible with the update. Administrator did not know it would affect some resident tv’s until 5/24/24 in which time she called 10 resident’s families to inform them of the issue and that the resident would need a new tv for the upgraded service. Per Administrator, R1 was one of those contacted. On 5/24/24 when a call was made to residents, administrator provided an alternative that residents can use the community TV temporarily. It was also offered that the administrator would go on 5/25/24 to purchase TVs for residents whose families agreed to the purchase and those residents would reimburse the facility for the cost of the TV. Only one resident’s family agreed to have this done. Administrator stated in conversation with F1, F1 said if they were feeling well they would bring one “this weekend”. Administrator also stated a comment was made to F1 that if there was an extra donated TV that would work they would give that to R1, but there was not one after review of their inventory. Continued on 9099-C TV services is noted in the admission agreement stating “Basic services included” … “the option to connect to cable television.” The agreement does not state the facility will provide a TV, and in interviews conducted with facility, they stated personal TVs are not included in their services. On 6/1/24 a new remote was purchased for R1’s TV, hoping that would correct the problem with their TV being incompatible, but it did not. On 6/4/24, due to no TV being provided by the family a TV from a respite room was brought in to R1’s room. On 6/10/24 LPA Rankin observed a TV in R1’s room with a news channel broadcasting which picture coming in clearly. Administrator stated she had seen F1 visiting on the weekend but had not appeared to bring in a newer TV. Based on interviews and the information obtained, there is not enough evidence to prove the allegation of, “Staff did not ensure resident receives contracted amenities” and it is unsubstantiated at this time. Exit interview conducted, copy of report given.the state’s words, verbatim · CDSS document, Jun 10, 2024 · control 29-AS-20240524153030

Allegation investigated: Staff did not provide proper notification of rate increase. Facility staff did not communicate with authorized representative.

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Sanjuana Enriquez and explained the purpose of the visit. On the allegation: Staff did not provide proper notification of rate increases. It was alleged the facility did not notify the Family 1 (F1) for Resident 1 (R1) that there would be rate increases. Unsubstantiated Interviews conducted on 5/24/24 at 3:45 pm and 5/31/24 at 8:10 am with F1 resulted in F1 stating no notification of increases had been provided prior to the invoices being received. F1 provided invoices showing the increases effective 9/1/23 and a second increase effective 4/5/24. F1 stated they had attempted to contact the facility administration regarding the increases starting in February to May of 2024 with no response until a conversation and email were done with the Business Office Manager on 5/20/24. F1 stated this was the first time they had received this notice. During the interview with F1 they stated in April 2024 the facility placed a “bracelet” on R1, following that F1 drove to the facility to discuss this with the administrator. Per F1, this discussion regarding the “bracelet” did occur in person. F1 did not state they addressed the increase concern with the administrator during this meeting. On 5/28/24 at 9:45 am LPA Rankin arrived at the facility and at 10:00 am requested copies of admission agreements, fee schedules, financial invoices, and correspondence / notifications for R1. LPA reviewed invoices dated 7/1/23 to 6/1/24. LPA requested documents showing correspondence for a sampling of residents that had been notified of rate increase over the past year, as well as any of R1’s notifications. Copies of notifications were provided promptly. The documents provided during the visit showed a letter dated 7/3/23 for R1, addressed to “(name of R1) C/O (name of F1)” showing the 60-day notification of the first-rate increase effective 9/1/23, and a document showing a 60-day notification of a second-rate increase for a “revised resident assessment” putting R1 into Level II range, this was dated 2/5/24 with the rate increase taking effect 4/5/24. The invoices provided to the LPA by both parties show the increases started per the effective date noted on the 60-day notifications. Notifications both have “First Class Mail” noted at the top of the letter. LPA provided assistance and recommended the facility send rate increase notices via certified mail, email, or somehow document notification was sent to show proof of correspondence. Continued on 9099-c In a telephone interview on 5/30/24 at 3:21 pm, Administrator stated she had seen F1 on various occasions, one of which was during a visit to discuss R1’s Wander guard bracelet. The administrator stated during that in-person discussion, at no time did F1 bring up the concern of the rate increase. Administrator stated F1 visits R1 regularly and has not tried to discuss rate increases. Based on interviews, and documentation obtained, there is not enough evidence to prove the allegation of, “Staff did not provide proper notification of rate increase” and it is unsubstantiated at this time. On the allegation: Facility staff did not communicate with authorized representative. LPA interviewed F1, who stated they have made attempts to contact facility administration and have not received responses. F1 does not have any documents in writing showing the attempts, and both parties have stated they had conversations in April and the rate increase concern was not brought up. When LPA spoke with Administrator to confirm her process for responding to and communicating with family and residents, she stated she and her staff have been responding to inquiries in a timely manner. She also stated that when voicemails are left, the voicemail is sent to her email so when she isn’t in-person at the facility, she is still getting notified so she can respond promptly, the same process occurs for Amy Bowman. On 6/10/24 an advisory was given to document conversations, and/or possibly follow-up with emails with residents and/or family who are appearing to start to elevate concerns so that they can provide documentation and support that all efforts were made to respond to concerns. Based on interviews and the information obtained, there is not enough evidence to prove the allegation of, “Facility staff did not communicate with authorized representative” and it is unsubstantiated at this time. Exit interview conducted, copy of report given.the state’s words, verbatim · CDSS document, Jun 10, 2024 · control 29-AS-20240520154222

Allegation investigated: Staff made inappropriate comment towards resident

Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegation above. LPA Olson and Miller interviewed Staff and Administrator on 12/15/23 and requested relevant documents. LPA met with Administrator and explained the purpose of the visit. On the allegation: Staff made inappropriate comment towards resident. It was alleged that Staff stated a resident with dementia was “ pathetic “ because they needed help being assisted back to their room. LPA interviewed the staff who stated they had just called for a care staff to come assist the resident back to their room. They thought they were just talking to a co-worker and said, it’s pathetic that you can’t get back to your room when you have dementia. Staff stated there was no one else in the room at the time and there was no way anyone overheard. Staff also stated they would never say anything like that to a resident or around residents. Staff said they have a family member with dementia, and it is a very sensitive topic for them. Continued on 9099-A Unsubstantiated They also said they meant no disrespect and was not calling the resident pathetic. Based on the information obtained the allegation is deemed Unsubstantiated. LPA issued Technical Assistance to Administrator stressing they review with staff the importance of how they talk to and about residents and confirm all staff are up to date on Residents Personal Rights. Exit interview conducted, copy of report issued.the state’s words, verbatim · CDSS document, Feb 2, 2024 · control 29-AS-20231211123120

Allegation investigated: Staff did not meet resident’s hygiene needs Resident was charged for services not rendered

Licensing Program Analysts (LPA's) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. LPA interviewed reporting party on 11/22/23 and 2/2/24, interviewed Staff and residents on 11/27/23 and requested relevant documents, interviewed Administrator on 12/15/23 and 2/2/24, and staff and residents on 12/15/23 and 2/2/24. LPA met with Administrator and Wellness Director over the phone and explained the purpose of the visit. On the allegations: Staff did not meet resident’s hygiene needs and Resident was charged for services not rendered. It was alleged Resident 1 (R1) is paying for 2 showers a week but sometimes doesn’t get their shower and the facility refuses to refund R1. Interviews revealed R1 has a shower log to track the showers R1 receives. It was alleged that on 10/31/23 a staff member called off so R1 was unable to get their shower. Interviews with staff confirmed if there are any call offs Residents don’t receive their shower and the next shift will “try” to complete it. If a resident refuses a shower the policy is to inform the Medtech, the Medtech attempts to shower the resident and if they refuse again they are to inform the Wellness Director. Continued on 9099-C Substantiated Wellness Director stated the shower is then put on the next shift to try to complete the shower. LPA interviewed the Medtech to ask how often showers are refused. Medtech stated there are around 2-3 refusals a week. Medtech stated a resident refused a shower on 11/27/23 (day of interview), they attempted to give the shower and it was refused again, and they were going to inform the Wellness Director. LPA asked if they inform the Medtech coming on the following shift that it was missed and Medtech said no, it’s the caregivers responsibility. LPA interviewed the resident who refused the shower and interviews revealed they didn’t in fact refuse, they just said they weren’t allowed to get their feet wet. LPA asked resident if they gave the caregivers a suggestion how to shower them without getting their feet wet and they said no, that’s the staff’s job to figure out. Resident stated this happens a lot and they don’t receive showers due to this. LPA interviewed Wellness Director who stated they are going to hold an in-service to address showers and better train staff on questions to ask and ways to overcome obstacles of missed showers. LPA observed staff to not have a clear system or way to know if residents missed their shower and could easily forget to tell the next shift. LPA reviewed October and November shower log for R1 which states “resident not available” on 10/24/23 and 10/27/23 and indicates a shower was not given to resident on 10/31/23. On 1/24/24 Wellness Director stated they implemented a new shower sheet that will be used to make up missed shower schedules. On 12/15/23 Interview with Administrator revealed they are only aware of one missed shower on 10/31/23 and offered to refund the missed shower but the family wanted more refunded. R1 implemented their own system where caregivers sign off when showers are due and then when they are given. LPA observed 9/19/23 say "unable to have shower because someone took all of my towels out of the bathroom". 10/17/23 says "no shower" and 10/31/23 "Unable to have shower, only 1 caretaker." On 2/2/24 interviews revealed the facility issued a refund for the three missed showers on the February 2024 bill. Based on the information obtained, the allegations Staff did not meet resident’s hygiene needs and Resident was charged for services not rendered are deemed Substantiated. Exit interview conducted, copy of report and appeal rights issued. Director stated if this reset doesn’t work they will send a technician to come and fix it. On 12/15/23 Administrator stated the cable company came on and fixed both boxes. LPA interviewed Maintenance Director on 2/2/24 that stated since the cable company came out the channels are working better but R1's TV is the problem and skips channels but they are not missing. LPA interviewed R1 who stated the TV gets fixed for a few days then goes back to not working. LPA reviewed the facility’s Admission Agreement which indicates cable services are provided. The Admission Agreement does not delineate the specific channels that will be included/ available in the cable package. Based on the information obtained, the allegation is deemed Unsubstantiated. Exit interview conducted, copy of report issued.the state’s words, verbatim · CDSS document, Feb 2, 2024 · control 29-AS-20231117112744

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Feb 9, 2024

87464 Basic Services (f)(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications... This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply in the section sited above when staff did not properly assist resident with showers or have a system to make up missed showers which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 2, 2024

Plan of correction: Facility implemented a new shower log to better track missed showers. POC is was cleared at the time of the visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(c) · Plan of correction due date: Feb 9, 2024

87507 Admission Agreement (C) Any fee that is charged prior to or after admission, shall be clearly specified. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply in the section sited above when staff did took 4 months to agree on a refunded shower amount, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 2, 2024

Plan of correction: Facility issued a refund. POC cleared during the visit.

Allegation investigated: Staff mismanaged resident medication Facility does not have adequate staff to meet residents needs Facility did not follow admissions agreement Facility is not kept clean

Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. LPA interviewed reporting party on10/23/23, interviewed Wellness Director and Care Staff on 10/25/23, 11/27/23, 12/15/23 and 2/2/24 and requested relevant documents. LPA met with Administrator and Wellness Coordinator over the phone and explained the purpose of the visit. On the allegation: Staff mismanaged resident medication. It was alleged that Resident 1 (R1) received three times the amount of medication Warfarin that the doctor ordered. It was alleged that R1’s blood clotting International Normalized Ratio (INR) reading was 8 when the normal is between 2 and 3. LPA received a call from the Wellness Director who informed LPA of the medication error. On 10/25/23 LPA interviewed staff that stated they did not read the label for the medication. They provided R1 the medication the day before and it was a 1mg tablet, and assumed the medication was the same, when in fact the medication had changed to a 3mg tablet. The physician’s order indicated to give 1.5 tablets of the 1mg tablet, and the med tech gave 1.5 tablets of the 3mg tablet. Continued on 9099-C Substantiated Staff stated they know they should have checked the bottle and will read the label and not assume again. The resident’s physician was contacted and the resident was immediately placed on additional wellness checks. Wellness Director stated the staff was retrained and written up for the medication error. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility does not have adequate staff to meet residents needs. It was alleged that due to there being only one Med Tech for around 100 residents, they are too rushed due to providing so many medications to so many residents. It was also alleged that there are not enough staff to adequately meet residents needs and Resident 1 and Resident 2 (R1 and R2) were so neglected that they decided to hire private caregivers. It was also alleged R2 fell, was bleeding from their lip and no caregiver noticed it. Reporting party stated R2 has dementia and is on the highest level of care but staff are too busy to check on R2. LPA interviewed Staff and Residents. Most staff and residents stated the facility is under staffed. There are usually 2 staff scheduled, sometimes 3. Staff and residents stated sometimes staff call out and one caregiver has to cover all four floors and 90-100 residents by themselves. Staff and residents also stated they thought one med tech was not enough to meet all the medication needs of residents. Interviews with staff on 12/15/23 stated staffing has gotten better and now they are only left alone around once per week, not two or three times as was previously. Staff also stated they check on R1 and R2 multiple times a day in the AM and PM when they do not have their private caregiver. Administrator and Wellness Director stated when they discovered R1 and R2 hired private caregivers they tried to hold a meeting but family never wanted to meet. Administrator stated one medtech is enough because not every resident is on Medication Assistance. When asked about staffing Wellness Director stated they have two staff scheduled in the AM and PM and caregiver come mid shift if needed. LPA observed staff schedules from October through December 2023. LPA observed 2-3 caregivers and one med tech scheduled each shift. Administrator stated if there are any call outs Wellness Director or Wellness Coordinator come in and help cover. Based on the information obtained, the allegation is deemed Substantiated at this time due to multiple staff stating they are left alone to escort, respond to pendants, deliver food for almost 100 residents at least once per week. On the allegation: Facility did not follow admissions agreement. It was alleged that residents are not receiving housekeeping, there are often diapers on the floor and beds aren’t made. It was also alleged residents’ teeth aren’t being brushed, dressing assistance isn't being provided, and showers aren’t given per the Admission agreement. LPA interviewed staff and residents. Interviews revealed housekeeping comes and deep cleans once a week, and certain residents get daily housekeeping for an extra fee. Continued on 9099-C Staff and Residents stated housekeeping isn’t perfect but if a caregiver observes a dirty room they will call housekeeping to come clean it and they usually do. Staff interviewed stated there are some days (usually weekends) when there is only one housekeeper and they can’t clean everything so the caregivers have to. LPA interviewed Residents and Staff about grooming assistance. Staff stated they brush residents teeth daily and help get them up and dressed if needed per their care plan. When asked about showers staff state if a staff calls off, showers don’t get done and if someone refuses a shower they let the Med tech know and they try. LPA interviewed Med tech on 11/27/23, who stated today a resident refused a shower, they tried to shower them and they refused and was going to let the Wellness Director know. LPA asked if they inform the Medtech coming on (the following shift) that it was missed and Medtech said no, it’s the caregivers responsibility. LPA spoke to this resident who stated they did not refuse a shower they just didn’t want their feet to get wet. LPA asked if staff offered ideas on how to shower them without getting their feet wet and they stated no, that is their job to figure out. LPA informed the Wellness Director who stated they had already planned an in-service training on showers and will train staff to ask questions and overcome simple obstacles. Resident’s interviewed had mixed opinions on receiving their proper care and showers per admission agreement. Incontinent residents stated they don’t believe they are checked on every two hours. Residents stated they may be checked on 3-4 times throughout the day. Staff interviewed stated they try to complete everything on their Plan of Care (POC) but it’s hard to do everything with only 2 staff and they can’t be everywhere at once. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility is not kept clean. It was alleged that the dining room tablecloths are stained and dirty, not clean. LPA observed the dining room and tablecloths on 10/15/23 after breakfast, before lunch service. LPA observed four tablecloths to be dirty and stained. Staff interviews revealed they change tablecloths after lunch, before dinner and use a linen company. Staff stated the linen company sometimes send tablecloths with stains, and they have no choice but to use them. LPA recommended to staff to try and ask the company to not send dirty tablecloths or switch to a different color (other then white). On 12/15/23 LPA observed no dirty tablecloths. Based on the information obtained, the allegation is deemed Substantiated at this time. A technical Violation was issued. A civil penalty for a repeat violation for $250 was assessed. An exit interview was conducted, a copy of the report, Civil Penalty, and appeal rights were issued.the state’s words, verbatim · CDSS document, Feb 2, 2024 · control 29-AS-20231020141823

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 3, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply in the section sited above when staff did not properly assist resident with medications and issued the incorrect dose which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 2, 2024

Plan of correction: Wellness Director held in service trainings with all med techs on the importance of the 7 medication rights. POC cleared during the visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Feb 9, 2024

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement was not met as evidenced by: Based on interviews, the licensee did not comply in the section sited above when staff were not sufficient in numbers at all times to meet resident needs, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 2, 2024

Plan of correction: Licensee shall submit a staffing plan showing adequate amount of staff to meet resident needs, including no less than two dedicated care staff on shift on all times.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Feb 2, 2024

87464 Basic Services (f)(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing.... This requirement was not met Based on interviews and record review, the licensee did not comply in the section sited above when staff did not properly assist residents with showers or have a system to make up missed showers which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 2, 2024

Plan of correction: Facility implemented a new shower log to better track missed showers. POC is was cleared at the time of the visit.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Olson conducted a Case Management - Incident visit to issue deficiencies on a medication error the facility self reported. LPA met with Administrator and Wellness Director over the phone and explained the purpose of the visit. CCL received an incident report on 01/27/24 stating that on 01/21/24 Staff 1 (S1) prepared 2 different medications at the same time and took the wrong one to Resident 1 (R1). R1 was given medications that could decrease respirations, resident was informed and the doctor was called immediately. R1 was given the option to go to the ER but they declined so care staff monitored R1 in their room, one-to-one for respiratory depression until 4am and then twice per shift from 1/22/24 through 1/24/24. Staff 1 was written up and retrained on the 7 resident rights by Wellness Director. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). A civil penalty for a repeat violation for $250 was assessed. An exit interview was conducted, a copy of the report, Civil Penalty, and appeal rights were issued.the state’s words, verbatim · CDSS document, Feb 2, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 2, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply in the section sited above when staff did not properly assist residents with medications and issued the incorrect dose which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 2, 2024

Plan of correction: From 1/24/23-1/26/24 Facility conducted an in service training for all med techs on the importance of live passing medications and Wellness Director met with each med tech individually for a knowledge check on live pass. POC was completed at the time of the visit.