Senior Beginnings @ Julia's Cottage

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Licensee Stuart Neave. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, ages 60 and over, one of which can be bedridden in rooms 1, 5, or 6. Hospice waiver approved for three (3). During today’s inspection there were 6 residents in care. LPA and Licensee toured the interior and exterior of the facility and inspected a sample of rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Licensee, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Licensee Stuart Neave, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jul 31, 2026

Allegation investigated: Resident was abused while in care

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegation. LPA identified herself to and was granted entry by Caregiver Lucita Credito. Administrator John "Stuart" Neave arrived during the visit, and LPA explained the purpose of the visit. During today's visit, LPA observed residents in care and reviewed facility records. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that Resident 1 (R1) was abused by Staff 1 (S1) while at the facility, due to R1 yelling “don’t let (S1) touch me”. Review of R1's assessment and needs and service plan documents dated January 2024 revealed R1 required staff assistance with all activities of daily living, including transferring, bathing, and incontinence care and was a fall risk. Continued on LIC9099-C page... Unsubstantiated Interviews with outside sources, staff, and R1 and review of R1’s assessment records revealed that R1 had a diagnosis with major neurocognitive disease and had occasional verbal aggression and agitation. Interviews with staff and outside sources revealed that R1’s agitation often occurred when R1 was repositioned in bed for bathing or incontinence care due to a fear of falling. Additionally, staff stated that R1 would sometimes tell staff not to touch R1, and staff believed that it was due to R1’s pride and desire to maintain their independence. Interviews with staff and outside sources revealed that R1 would grab onto the bed rails while yelling, including when R1 yelled to prevent S1 from touching them, which supported staff and outside source beliefs that R1 was agitated due to a fear of falling. R1 denied any concerns regarding the care provided by the facility and the staff during interviews and stated that staff were nice to R1. Other residents denied any concerns with the facility and stated that staff are pleasant and responsive to care needs. The Department interviewed S1 who denied any inappropriate interactions with any residents, including R1. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Administrator John "Stuart" Neave, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, Sep 8, 2025 · control 08-AS-20240604110033

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit. LPA identified herself to, was greeted by, and explained the purpose of the visit to Administrator John "Stuart" Neave. On 7/9/2024, the Department received a self-reported incident report and report of suspected dependent adult/elder abuse (SOC341) from the facility that described the alleged incident where Staff 1 (S1) touched Resident 1 (R1) genitals. On 7/10/2024, the Department conducted a case management visit to conduct a health and safety visit and interviewed staff and residents. Review of R1’s assessment documents dated July 2023 revealed that R1 had a diagnosis of major neurocognitive disease, had short term memory loss, and required assistance with bathing, grooming, dressing, and toileting. Interviews with facility staff revealed that on 6/26/2024, staff overheard R1 tell another resident at the facility that S1 kissed R1’s face and touched R1’s genitals. When interviewed by the Department, R1 stated that S1 wanted a sexual relationship with R1 and had touched R1’s genitals while S1 showered R1. While R1 remained consistent in the accusation against S1 across multiple interviews, R1 was confused, disoriented to time, and unable to provide specific details regarding the incident, including if the incident had occurred multiple times. During R1’s multiple description of the incident, R1 provided details that did not make sense or contradicted R1’s previous descriptions of the incident. Interviews with staff, including S1, revealed that S1 was responsible for providing showers for residents, including R1. Interviews with other residents denied any issues with staff interactions and stated staff were pleasant, however, a resident had observed S1 kiss a resident on the cheek, which was supported by staff interviews. Continued on LIC809-C page... Staff denied being aware of any resident complaints regarding their interactions with S1. During interviews, S1 denied the allegation of inappropriate touching, either during bathing or otherwise. The evidence obtained during Department’s investigation did not meet the preponderance of evidence for a violation of regulations regarding the incident between R1 and S1. Interviews with facility staff revealed that staff did not report R1’s statements to facility management or any other agencies or other individuals, which interviews with facility management confirmed. Interviews with staff and facility management revealed that facility management became aware of the incident when R1 spoke to one of the Administrators on 6/28/2024. Review of incident reports and SOC341 submitted to the Department by the facility revealed that the incident was reported to the Department on 7/9/2024, eleven (11) days after facility management was made aware of the incident, and thirteen (13) days after staff became aware of the incident. Therefore, following deficiency was cited for reporting requirements and noted on the attached LIC809-D page. An exit interview was conducted with Administrator John "Stuart" Neave, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Sep 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Oct 8, 2025

87211(c) Any suspected physical abuse that does not result in serious bodily injury... shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours… This requirement has not been met as evidenced by: Based on interviews and records review, the Licensee did not comply with the section cited above in that R1’s report of sexual abuse was not reported within 24 hours. This posed a potential safety and personal rights risk of 5 of 5 residents.the state’s words, verbatim · CDSS document, Sep 8, 2025

Plan of correction: Administrator stated that staff and facility management would complete vendorized training on reporting requirements and submit proof of training completion for staff and facility management to the Department by POC due date of 10/8/2025.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Administrator John "Stuart" Neave. The facility is licensed for a maximum capacity of 6 non-ambulatory residents, 1 of which may be bedridden in rooms 1, 5, or 6. The facility has a waiver for 3 hospice residents. During today’s visit, the facility had a census of 5 non-ambulatory residents. The Administrator for the facility is John "Stuart" Neave and their certificate was valid and current. During today’s visit, LPA toured the facility and inspected resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 111.0 and 114.1 degrees Fahrenheit in bathrooms for resident use. The facility’s internal temperature was measured at 73 and 76 degrees Fahrenheit across the facility. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to "Stuart" Neave, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerators were kept at 40 and 45 degrees Fahrenheit, and the facility freezers were kept at 0 and -10 degrees Fahrenheit. Continued on LIC809-C page… LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. LPA reviewed multiple resident and staff records. LPA provided Administrator with consultation and guidance regarding the regulation changes that became effective 1/1/2025. An LIC9102TA Technical Advisory regarding record keeping was provided. No deficiencies were cited on today’s date. An exit interview was conducted with Administrator John "Stuart" Neave, whose signature below confirms receipt of a copy of this report, the LIC9102TA, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Sep 8, 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.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Alicia Acosta. Administrator John "Stuart" Neave arrived during the visit. The facility is licensed for a maximum capacity of 6 non-ambulatory residents, 1 of which may be bedridden in bedrooms #1, #5, or #6. The facility has a waiver for 3 hospice residents. During today’s visit, the facility had a census of 6 residents, 5 of which were non-ambulatory and 1 was on hospice care. The Administrator for the facility is John "Stuart" Neave and their certificate was valid and current. During today’s visit, LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 131.2 degrees Fahrenheit in both a common bathroom and a resident's private bathroom, as well as 121.3 degrees Fahrenheit in a common bathroom. The Administrator turned down the hot water heater during the visit. The facility’s internal temperature was measured at 73 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to "Stuart" Neave, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 40 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and at least one had a current first aid certificate. Continued on LIC809-C page… LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property, and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns. The Administrator will submit copies of the LIC500 Personnel Report, LIC610 Disaster Plan, and current liability insurance to the Department within 15 business days. The following deficiency was cited for hot water temperature and noted on the attached LIC809-D page. An exit interview was conducted with Administrator John "Stuart" Neave, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Jul 26, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to conduct follow up regarding a self-reported incident. LPA was greeted by, identified herself to, and explained the purpose of the visit with Administrator John "Stuart" Neave. On 7/9/2024, the Department received an incident report and report of suspected senior abuse (SOC341) from the facility that described an incident that occurred on 7/5/2024 between Resident 1 (R1) and Staff 1 (S1), which did not result in any injuries. [Administrator was provided with LIC811 Confidential Names List to identify individuals]. During today’s visit, LPA conducted a health and safety check, observed residents in care, reviewed facility records, and interviewed residents and staff. No immediate health or safety concerns were noted during the visit. Per Administrator, S1 voluntarily resigned and is no longer working at this facility as of today's visit. No deficiencies were cited on today’s date. An exit interview was conducted with Administrator John "Stuart" Neave, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Jul 10, 2024