Serra Sol

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Staff do not provide activities Staff do not follow reporting requirements

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as activity schedule. Regarding the allegations that staff do not follow reporting requirements and staff do not provide activities, the investigation revealed the following: Facility provided a death report for Resident 1 (R1) dated 06/19/2026 showing cause of death as natural. Resident was admitted to hospice care. Facility submitted an incident report for R2 eloping out of the facility on 05/02/2026. The department addressed the incident on 05/13/2026. LPA reviewed an extensive activity calendar including games, exercise, and coastal drives. LPA observed residents participating in activities. Per staff, all residents are allowed to participate in the activities and nobody is denied. Based on record review and observation, facility is reporting incidents and providing activities. CONTINUED ON LIC 9099C DATED 09/25/2026. Unfounded but that residents are generally all together in the common area so they are easily observed and checked. One out of five staff states sometimes residents are wet when the staff come on shift. Facility had an elopement incident with R2 on May 02, 2026 which was previously addressed by the department on May 13, 2026. The incident occurred when the resident was mistakenly identified as a visitor by staff that were present at the time. Facility denies knowledge of other elopement incidents but states there are residents who are exit seeking that staff monitor. During the investigation, LPA reviewed select resident medications and toured the medication room. LPA observed no evidence of any pre-pouring of medications and staff deny knowledge of pre-poured medications. LPA observed medications on hand match physician orders and medications appear to be administered per physician order. Five out of five staff deny knowledge of staff being rough with residents. LPA reviewed two SOC 341 reports indicating Staff 3 had been rough with residents. Administrator indicated the internal investigation showed the allegation came from personal disagreements between staff. Based on records reviewed and interviews conducted, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted and copy of the report was provided to the facility. Therefore, the allegations are deemed UNFOUNDED, meaning that the allegations are false, could not have happened and/or is without a reasonable basis. Exit interview conducted and copy of report providedthe state’s words, verbatim · CDSS document, Sep 25, 2026 · control 22-AS-20260706155046

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: Oct 9, 2026

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually.. four hours of which shall be specific to postural supports, restricted health conditions, and hospice care.... This requirement is not met as evidenced by: Based on record review, Licensee failed to ensure S1 and S2 received training on postural supports which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2026

Plan of correction: Licensee to conduct training and forward proof to LPA by POC due date.

Type of visit: Required - 1 Year

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 70 non-ambulatory residents. Facility has an approved hospice waiver for 12 residents. The facility has 41 current residents. Executive Director (ED) Christine Greenway assisted with the inspection. LPA along with ED toured the facility at 9:25 AM. LPA toured the physical plant, checked food service, and facility documentation. The facility is a two story building with three courtyards and surrounding parking lot. LPA inspected five resident bedrooms at random and verified they each had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 112.6 degrees F and 116.2 degrees F in five bathrooms checked. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Egress exit alarms were operational during today's visit. LPA observed residents moving around freely throughout the facility and utilizing the courtyard. LPA toured the kitchen and observed sufficient perishable and non-perishable food stocked at time of visit. Kitchen appliances were operational during today's visit. Outside grounds were toured. Courtyards were clear of hazards. There is shaded outdoor seating for residents. LPA observed the emergency food and water supply. Smoke detectors and fire systems were last serviced on 5/26/26 by Delta Fire Protection. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 3/23/2026. First aid kit contained all required items including tweezers, scissors and thermometer. LPA observed the evacuation chair installed by the stairs. Facility conducts activities in the form of exercise, art therapy, and games. LPA reviewed five resident files and six staff files. Four out of five resident files contained all required documentation including admission agreements, physician reports, and resident appraisals. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, and criminal record clearance. LPA reviewed medication storage and administration. Medications are stored in carts in the medication room. Medications are being administered per physician order. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Jun 10, 2026

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not properly address resident's multiple falls at facility.

On May 14, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced for the purpose of conducting a subsequent complaint investigation into the above allegation. LPA was greeted, introduced self, and was granted entry after stating the purpose of the visit to staff. Administrator (Admin) Christine Greenway was contacted via telephone and arrived shortly to assist with the visit. LPA reviewed copies of facility documents including: Resident Roster, Staff Roster, Resident #1's (R1's) Emergency Info & Contact Sheets, Physician's Reports, Admissions Agreement, Service Plan, Incident Reports, Physician Fax Communications, and hospital discharge records. Interviews were successfully conducted with staff and witnesses. Continue to LIC9099-C..... Substantiated The investigation revealed the following: Regarding the allegation, Staff did not properly address resident's multiple falls at facility, it is alleged that staff did not prevent Resident #1 (R1) from sustaining multiple falls while in care within a two year period. LPA inspected the facility, conducted health and safety checks on residents in care, and did not observe any health and safety issues during the visits. R1 moved into the memory care facility on October 4, 2021, and based on the Physician’s Report dated October 1, 2021, R1 was ambulatory, able to communicate needs, and had a diagnosis of Alzheimer’s Disease Dementia with delusions and behavior issues. A Physician’s Reports dated March 20, 2024 indicated R1 was non-ambulatory, able to communicate needs, and had the same diagnosis. LPA reviewed R1’s Physician Fax Communications sent by the facility and hospital discharge records which state that: on June 1, 2023, R1 sustained an unwitnessed fall and taken to the hospital for evaluation by family; on October 27, 2023, R1 was assessed by Home Health, was able to ambulate with normal gait pattern and with noted instability; on December 4, 2023 R1 sustained a witnessed fall resulting in R1 hitting their head and was transferred to the hospital for evaluation; on February 2, 2024, R1 was transferred to the hospital due to a fall; on February 24, 2024, R1 sustained an unwitnessed fall resulting in rug burn, an abrasion on her right elbow and first aid was applied; on February 25, 2024, R1 had an unwitnessed fall, ambulated and expressed pain on right elbow; on March 3, 2024, R1 sustained an unwitnessed fall in a common room, was able to ambulate and had no signs of pain or injuries; on April 7, 2024, R1 sustained an unwitnessed fall in their bathroom and staff observed bruising from a previous fall. Based on records reviewed, R1 nine sustained falls between June 1, 2023 and April 7, 2024 and voluntarily moved out on May 16, 2024. The facility held multiple care plan meetings between October 4, 2021 and February 1, 2024, however, R1 was not assessed to be a high risk for falls and additional measures to address R1’s fall risk were not included. Four out of four staff interviewed stated they are unaware of the fall prevention measures put in place for R1 and the facility was unable to provide any fall prevention plan documentation during the course of the investigation. LPA reviewed the facility’s staff schedule and did not note any staffing issues that may have contributed to R1’s falls. LPA interviewed R1’s responsible party who had concerns about the care R1 was receiving at the facility but did not provide any supportive evidence. Continue to LIC9099-C..... Even though R1 had no visible injuries during some of the falls, it was imperative that facility document and implement a fall prevention plan specific to R1’s Dementia diagnosis. Therefore, based on the Department’s interviews that were conducted and the records reviewed, the preponderance of evidence standard has been met, and the following allegation: Staff did not properly address resident's multiple falls at facility is deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. A deficiency is being cited on the attached LIC9099D. An exit interview was conducted with Administrator Christine Greenway, a copy of this report, LIC809-D, LIC811, and appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, May 14, 2026 · control 22-AS-20260312123306

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: May 22, 2026

87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on interviews and record review, licensee did not find a solution necessary to prevent R1’s from sustaining multiple fall and a fall risk plan was not implemented, which posed an potential Health, Safety, and/or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 14, 2026

Plan of correction: Executive Director, Christine Greenway, stated that all care staff will be trained to meet all residents’ fall needs, and will submit an Acknowledgement of Understanding of the said deficiency. The above statement and training records will be submitted to LPA via email by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. LPA met with Executive Director Christine Greenway and explained the reason for the visit. On May 8, 2026, the Agency received a special incident report (SIR) that Resident 1 (R1) left the facility unattended on May 2, 2026. On May 2, 2026 at 2:01 pm R1 left the facility for 20 minutes and returned. Staff reported that R1 was thought to be a visitor and allowed to leave the facility by mistake. Non-care staff were present when R1 left the facility. When R1 returned they were assessed by care staff and no injuries were noted. R1 was placed on 48 hour alert charting with increased checks upon return. R1's responsible party and primary care physician were notified. A review of records shows that R1's last doctor's visit was on April 27, 2026. R1's physician report dated June 5, 2024 states R1 cannot leave the facility unassisted. The Administrator reported that R1 is on increased checks and his care plan has been updated to include wandering behavior. Facility is responsible for R1 and the facility is a memory care facility. Staff verified R1 left the facility unattended. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.the state’s words, verbatim · CDSS document, May 13, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: May 14, 2026

(f) Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by... R1 left the facility unattended on May 2, 2026, R1 is not allowed to leave the facility unassisted, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 13, 2026

Plan of correction: Licensee agrees to conduct an in-service training for all staff members on CCR 87464 and provide a copy of the sign-in sheet for all staff in attendance. Licensee agrees to provide an outline of topics covered in the in-service, including the duration of the in-service training and a list of all participants. Proof of correction to be sent to the LPA.

Allegation investigated: Staff left residents in soiled diapers for an extended period of time Staff allowed resident to leave the facility without staff supervision Staff did not provide nutritious meals to residents in care Staff did not store food in a safe and healthful manner Staff did not follow proper reporting requirements

On April 17, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to continue the investigation into the allegations listed above and deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Christine Greenway was present and assisted on today's visit. During the course of the investigation, the Department interviewed residents, interviewed staff, inspected the facility's food storage areas, reviewed and obtained pertinent documents for this complaint. Regarding the allegation, staff left residents in soiled diapers for an extended period of time, the following has been concluded: The Department conducted eight resident interviews. Eight out of the eight residents interviewed denied the allegation and reported that they were satisfied with the care provided to them. The eight residents also reported that staff are quick to help them if they ever need assistance. The Department conducted six staff interviews. Six out of the six staff interviewed denied the allegation and stated that residents are always changed timely. CONTINUED ON LIC9099-C Unsubstantiated Regarding the allegation, staff allowed resident to leave the facility without staff supervision, the following has been concluded: The Department conducted eight resident interviews. Eight out of the eight residents interviewed denied the allegation and stated that they have never been left without staff supervision. The Department conducted six staff interviews. Six out of the six staff interviewed denied the allegation and reported no knowledge of an incident in which a resident was able to leave the facility without staff supervision. Regarding the allegation, staff did not provide nutritious meals to residents in care, the following has been concluded: During the investigation, the Department inspected the food that was being provided to the residents in care. The Department observed the facility provided various fruit and vegetable options, as well as different protein sources. The Department observed the food to be of good quality and to be free of any mold. The Department conducted eight resident interviews. Eight out of the eight residents interviewed denied the allegation and reported that they were satisfied with the food that is served to them. The Department conducted six staff interviews. Six out of the six staff interviewed also denied the allegation. Regarding the allegation, staff did not store food in a safe and healthful manner, the following has been concluded: The Department inspected the facility's food storage areas during it's visits on November 26, 2025, and on April 17, 2026. During both visits, the Department observed food to be stored in appropriate containers and to be labeled. The Department observed the food to be free of any mold and observed that the facility takes all the necessary precautions to store food safely. The Department also observed the facility's kitchen areas to be clean. The Department conducted six staff interviews. Six out of the six staff interviewed denied the allegation and stated that food is stored in a safe manner. Regarding the allegation, staff did not follow proper reporting requirements, the following has been concluded: The Department conducted six staff interviews. Six out of the six staff interviewed denied the allegation and stated that the facility has always followed the reporting requirements. The six staff interviewed also stated that the appropriate parties, such as families and doctors, are always notified when an incident occurs. CONTINUED ON LIC9099-C Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the five allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Christine Greenway and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 17, 2026 · control 22-AS-20251126091815

Allegation investigated: Licensee does not ensure facility has sufficient staffing to meet the needs of residents in care Staff allow residents to be left in soiled clothing for extended periods of time Staff do not ensure residents are provided assistance with meal service Staff do not ensure all residents receive bathing services Staff do not ensure residents are provided with social activities for engagement and interaction.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator Christine Greenway and explained the reason for the visit. The investigation into the allegation, Licensee does not ensure facility has sufficient staffing to meet the needs of residents in care, revealed the following. It was reported that the facility does not have enough staff to ensure residents are being escorted to meals, being showered, dressed and groomed properly and being assisting with all of their activities of daily living. The Administrator, Lindsay Schroeder, reported that the facility is fully staffed and they haven't had any staffing issues or complaints. LPA reviewed the staff schedule for November and December 2024. The schedule shows that for the from 6:00 am until 10:00 pm there are 4 caregivers and 1 medication technician (med-tech) and for the overnight shift (NOC) there are 2 caregivers and 1 med-tech are scheduled. 7 out of 7 staff interviewed (med-techs and caregivers) reported no issues with staffing. Unsubstantiated In addition to the caregivers, there is the Administrator, Wellness Director, head chef, 2 kitchen staff and one housekeeper and the maintenance director. A review of incident reports shows, the facility submitted 3 incident reports for November 2024 and 5 for December 2024. None of the reports required any type of follow up. The number of reports received for the facility is no cause for concern. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff allow residents to be left in soiled clothing for extended periods of time, revealed the following. R1 moved into the facility on November 1, 2024 and moved out of the facility on December 18, 2024. It was reported that on November 30, 2024, Witness 1 (W1) went to visit Resident 1 (R1) and found R1 in soiled clothing. W1 reported that R1 was shaking because they were not fed, did not receive their medicaiton and was in soiled clothing after an incontinence issue. No other details were provided. A review of R1's progress notes shows no incidents or issues reported for November 30, 2024. There is no mention of incontinence issues for R1 in any of the progress notes. 5 out of 5 caregivers interviewed reported that none of the residents including R1 have been left in soiled clothing and are assisted immediately. 5 out of 5 caregivers interviewed reported that R1 does wear incontinence briefs but is very good at going to the bathroom and is easily identified if they need to be changed. 7 out of 7 staff interviewed (caregivers and med-techs) reported they are unaware of any incidents on November 30, 2024, involving R1 shaking or being in soiled clothing. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff do not ensure residents are provided assistance with meal service, revealed the following. It was reported that R1's weight dropped because they were not being served breakfast or lunch and they were not escorted to the dining area. It was also reported that on November 30, 2024, when W1 visited R1, R1 was shaking because they not fed breakfast or lunch. R1 moved out of the facility on December 18, 2024 and their location is unknown so they were never interviewed. W1 reported that R1 did not eat breakfast or lunch on November 30, 2024, but they were not at the facility during breakfast or lunch hours. 5 out of 5 caregivers reported that R1 never missed a meal and was always escorted to each meal. A review of R1's progress notes does not show any entry for November 30, 2024 or any issues regarding meals. The Wellness Director and the Administrator reported that they never received any reports or complaints regarding R1 or any resident concerning meal service or eating issues. The Wellness Director and the Administrator reported that they have not received any complaints concerning R1 and their medications. Based on the evidence gathered the allegation is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with the Administrator and a copy of the report was provided. None of the evidence gathered supports the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff do not ensure all residents receive bathing services, revealed the following. It was reported that R1 was not receiving bathing services daily and R1 would only receive a bath/shower when R1's family provided it during their visits. W1 reported that staff had told them none of the staff every gave R1 a bath or shower. W1 did not provide any details or names of the staff involved. The Wellness Director reported that most residents are showered 2 or 3 times a week and as needed if one is required. The Wellness Director reported they are unaware of any resident not receiving regular showers. The Administrator and Wellness Director reported that no one has complained to them about not receiving showers. A review of records shows that on R1's care plan completed at the time of move in, R1 is to receive 2 showers a week on Mondays and Fridays at 9:00 am, and as needed. 5 out of 5 caregivers interviewed reported that R1 received showers on Mondays and Fridays and on most days when family visited. 5 out of 5 caregivers reported that R1's family would regularly shower R1 and dress and groom them. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff do not ensure residents are provided with social activities for engagement and interaction. It was reported that staff did not interact with R1 and did not provide R1 with social activities. W1 reported that staff would take R1 to the activity room and leave them there without interacting with R1 or attempting to have R1 participate in a group activity. The Activities Director reported that each day staff encouraged R1 to participate in group activities (stretching, balloon toss), music activities (singing and dancing) and craft activities (painting), and R1 showed no interest in any of them. 3 out of 5 caregivers interviewed reported that R1 preferred to be in the TV room and watch TV. The Activities Director reported that R1 was always encouraged to participate and would sit for a minutes and then walk to the TV room. The Administrator and the Wellness Director reported that they never received any complaints regarding R1 and activities. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Apr 15, 2026 · control 22-AS-20250106132300

Allegation investigated: Staff did not seek medical attention for resident in a timely manner Staff ordered medications for resident in care without proper authorization Staff did not report resident's incidents to appropriate parties

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigaiton into the allegations listed above. LPA met with Administrator Christine Greenway and explained the reason for the visit. The investigation into the allegation, staff did not seek medical attention for resident in a timely manner, revealed the following. It was reported that 3 separate incidents took place involving Resident 1 (R1) that required medical attention and the facility did not seek medical attention for R1 in a timely manner. The first incident was in January 2025 and R1 had diarrhea for multiple days, the second incident R1 had a swollen toe on April 1, 2025 and the third incident on April 22, 2025, R1 had constipation. R1 lived at the facility December 31, 2024 from until May 2, 2025. A review of progress notes for R1 shows that on January 13, 2025 R1 had loose bowel movements and staff assisted R1 with changing their clothes and showering. Staff 1 (S1) reported that they contacted R1's responsible party, primary care physician (PCP) and the Wellness Director. Unsubstantiated S1 reported that R1's responsible party arrived at the facility shortly after the call and took R1 to urgent care. S1 reported that normally they would wait for the physician or nurse practitioner to respond with a prescription or over the counter (OTC) medication to administer to the resident but R1's responsible party decided to take R1 to urgent care and when they returned they had prescriptions and medications for R1 to treat R1. The Wellness Director reported they were notified about the issue and spoke to R1's responsible party who informed them all the facility had to do was administer the medication. The Wellness Director reported that the prescriptions and medication prescribed for R1 were all verified so they administered the medication. The facility followed their procedure for the incident and contacted R1's PCP and were waiting for a response from R1's PCP on how to proceed. S1 and the Wellness Director reported it was not an emergency that required hospitalization or emergency services so an ambulance and/or 911 were not called. R1's responsible party verified that they took R1 to urgent care right after receiving the call from the facility. A review of R1's progress notes shows R1 saw their nurse practitioner on April 1, 2025, at the facility and R1 was observed to have swollen feet and a swollen toe. Medications and blood tests were ordered for R1 after the visit. On April 3, 2025 the blood draw was completed and on April 4, 2025 the new medications arrived and administered to R1. There was no mention of any swelling for R1 mentioned prior to April 1, 2025. On April 22, 2025 R1 was observed to have constipation. S1 and the Wellness Director informed R1's PCP and responsible party. S1 and the Wellness Director reported that the responsible party requested they give R1 prune juice. S1 reported they complied with the request. S1 reported that the issue wasn't an emergency and R1 did not report they were in pain so they waited for R1's PCP to respond to the report. The Wellness Director reported that R1's responsible party came to the facility to visit R1. The Wellness Director reported that the responsible party told them that R1 had a bowel movement and they were fine so they were taking R1 back home. The Wellness Director reported that R1 never returned to the facility and they never heard from R1 or they responsible party again. In each instance R1 received the proper medical care required and the facility responded in the proper manner and sought non-emergency medical care. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff ordered medications for resident in care without proper authorization, revealed the following. It was reported that the Wellness Director ordered medications for R1 and had the orders filled without proper authorization on January 6, 2025. The Wellness Director denied the allegation and reported that they met with R1's responsible party on January 6, 2025 and informed them R1 was displaying exit seeking behavior and was having a hard time adjusting to their new environment and suggested visiting R1 and having some more items from home in their room. 2 out of 2 med-techs interviewed and the Wellness Director reported that they only follow doctor's orders and don't recommend medications and suggest responsible parties should contact the physician if they have questions or concerns about medications. A review of records shows R1 moved in (December 31, 2024) with 8 prescribed medications and after seeing their nurse practitioner after move in, they were prescribed 1 additional medication with an order date of January 12, 2025. R1's was prescribed 17 different medications at the time move out. A review of records shows all medications were prescribed by a physician or nurse practitioner. None of the evidence gathered supports the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff did not report resident's incidents to appropriate parties, revealed the following. It was reported that R1's responsible party was not properly notified about incidents concerning R1 and that the facility didn't report the incidents to Community Care Licensing (CCL). The first incident was in January 2025 and R1 had diarrhea for multiple days, the second incident R1 had a swollen toe and feet on April 1, 2025 and the third incident on April 22, 2025, R1 had constipation. R1's responsible party verified they were notified about each incident. The Wellness Director and Staff 1 (S1) reported that none of the incidents were an emergency and R1 reported no pain. The Wellness Director and S1 reported that no of the incidents threatened R1's health, safety or well being. A review of records shows each incident was resolved and the first 2 incidents medication was ordered and administered within days of the report with no reported issues. Based on a review of facility records and California Code of Regulations, Title 22, (CCR) 87211 reporting requirements, none of the reported incidents rose to the level of submitting an incident report because all of the incidents were minor and the welfare, safety or health of R1 was not threatened. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Apr 15, 2026 · control 22-AS-20250501140051

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced case management visit. The Agency (Community Care Licensing) received a report on February 20, 2026, that there was no staff at the facility and the residents had no supervision. LPA met with Administrator Christine Greenway and explained the reason for the visit. The Administrator reported that 3 caregivers did not report to work for their 6:00 am shift, but the overnight staff covered the shifts until other staff members were called in to work. The Administrator reported that at no time were residents left unattended. LPA and the Administrator toured the facility. LPA observed 17 staff members at the facility during the visit of which 4 are care staff. The Administrator reported that they are arranging for additional care staff through an agency and are actively hiring additional care staff. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Feb 20, 2026

Allegation investigated: Residents left unattended for extended periods of time Facility staffing is not sufficient to meet resident's needs

LIcensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to continue the investigation into the allegations listed above. LPA met with Operations Specialist Becky Langdon and explained the reason for the visit. During the course of the investigation LPA toured the facility, interviewed staff and residents and reviewed faciltiy and resident records. The investigation into the allegation, Residents left unattended for extended periods of time, revealed the following. It was reported that Resident 1 (R1) was left unattended in their bed for 13 hours and no staff checked in on them during the 13 hours they were in bed. No other details concerning this allegation were provided. R1 moved into the facility on September 10, 2021 and went to the hospital on September 22, 2021 and never returned to the facility. R1 has been diagnosed with Dementia. 5 out of 5 staff members interviewed reported that none of residents including R1 have ever been unattended and left in bed for 13 hours. A review of R1's observation notes does not show R1 ever spent 13 hours in bed. Unsubstantiated The investigation into the allegation, facility does not have complete resident records, revealed the following. It was reported that Resident 2 (R2) did not have a care plan and no medication records. A review of facility records shows R2 moved in September 24, 2021 and had a care plan dated September 23, 2021 and a care plan dated October 6 and a medication list for September 2021. LPA reviewed 3 other resident files for Resident 1 (R1), Resident 3 (R3) and Resident 4 (R4). No discrepancies observed. Based on the evidence gathered the allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The investigation into the allegation, facility did not have a resident appraised, revealed the following. It was reported that R2 was not appraised. R2 moved into the facility September 24, 2021. A review of R2's records shows R2 was assessed on September 23, 2021 prior to move in and assessed on October 6, 2021 after they moved in the facilty. Based on the evidence gathered the allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The investigation into the allegation, facility staff is not properly trained, revealed the following. It was reported that Staff 1 (S1) had no training, experience or certifications. A review of records shows S1 had over 24 hours of training and 16 hours of on the job training (one on one training with another caregiver) in topics such as, care of residents with Dementia, basic care skills, providing medication assistance, resident rights and CPR certification. A review of 3 other caregiver files showed all 3 caregivers had 40 hours of initial training. Based on the evidence gathered the allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, facility staffing is not sufficient to meet resident's needs, revealed the following. It was reported that a lack of staff has resulted in multiple falls from residents. It also was reported that Resident 5 (R5) passed away at the facility. A review of records shows, R5 was sent to the hospital on July 9, 2021 and never returned to the facility. R5 passed away at the hospital on July 15, 2021. A review of the staff schedule for October and September 2021 show 18 caregivers and med-techs. 2 caregivers and 1 med-tech are scheduled for the AM shift (6am - 2pm) and PM shift (2pm-10pm). 1 caregiver and 1 med-tech for NOC shift (10pm - 6am). The Executive Director reported they are in the process of hiring more staff but at this time they only have 14 residents so there is enough staff to care for all the residents. 5 out of 5 staff reported there is enough staff to meet the needs of the residents. A review of incident reports received for September and October 2021 show only 2 incidents reports were received from the facility. One report noted a resident was found sitting on the floor and the other report noted a resident was lethargic. Neither report raised any concerns for the Agency and did not require follow up. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 22-AS-20211004152934

Allegation investigated: Staff mismanaged resident's medication. Staff did not ensure that resident ingested medications. Resident's records are not accurate. Staff is not communicating with resident's representatives in a timely manner. Staff did not respond to the front door exit alarm in a timely manner. Staff are serving food that does not meet individual needs.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met Operations Specialist Becky Langdon and explained the reason for the visit. During the investigation LPA interviewed staff, residents and witnesses and reviewed facility records. The investigation into the allegation, staff mismanaged resident's medication, revealed the following. It was reported that Resident 1 (R1) was given the incorrect dosage of medication. R1 moved into the facility on September 14, 2021, and moved out of the facility on October 18, 2021. R1 has been diagnosed with Dementia and did not respond to LPA’s questions. A review of R1’s medication records show R1 was prescribed 10 medications. A review of the R1’s medication administration record for September and October 2021, shows R1 was administered medication as prescribed. Unsubstantiated 3 out of 3 Med-techs interviewed reported R1 receives all their medication as prescribed. Witness 1 (W1) reported that R1 received more than the prescribed amount of melatonin, no dates or times were provided. W1 would not answer how they knew R1 received the wrong amount melatonin. There is no evidence to support the allegation, therefore the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff did not ensure that resident ingested medications, revealed the following. It was reported that med-techs would give R1 their medication in a paper cup and then walk away and did not ensure R1 actually took the medication. 3 out of 3 med-techs interviewed denied the allegation. R1 did not respond to LPA’s questions. W1 reported that they never witnessed a med-tech walk away from R1 before they took the medication. 3 out of 3 caregivers interviewed reported they had never witnessed a med-tech give a resident medication and walk away before the resident took the medication. None of the evidence gathered supports the allegation, therefore the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, Resident's records are not accurate, revealed the following. It was reported that R1’s resident information sheet (face sheet) had inaccurate information on it. No details were provided. LPA reviewed the information and verified the resident information, and the responsible party information was correct along with physician information. The Executive Director reported the information is correct to the best of their knowledge. R1’s responsible party would not verify any medical information. It is unclear what information was not accurate. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff is not communicating with resident's representatives in a timely manner, revealed the following. It was reported that the facility staff would not communicate with R1’s family regarding the status and condition of R1 or to provide requested documents like observation notes for R1. A review of incident reports for the facility for September and October 2021 shows only 2 incident reports submitted to the Agency and neither incident involved R1. There is no regulation regarding communicating with a responsible party unless it involves an incident that threatens the health, safety and welfare of a resident. The Executive Director stated that the Responsible Party/Power of Attorney for R1 has not requested any documents so none have been provided, and any other requests would be denied without the Power of Attorney’s permission. R1’s Power of Attorney reported that they have not requested any records for R1 and have no issues with communication with the facility. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff did not respond to the front door exit alarm in a timely manner, revealed the following. It was reported that Witness 2 (W2) exited the front door of the facility and the door alarm sounded and no staff responded to the door alarm. W1 reported that no one came to check the door. No date or time was provided for this incident. 1 out of 3 caregivers interviewed reported that they remember the incident. Staff 6 (S6) reported that they remember one afternoon (doesn’t remember the date) they saw R1’s family leaving the interior of the facility and exiting into the main lobby which has the front door to enter and exit the facility. S6 reported that the front door to the facility is not alarmed and does not make a sound when people open it. S6 reported that R1’s family pushed on the door leading to the lobby (which is delayed egress) and it opened, and the alarm went off and they left. S6 reported they were down the hall and saw that no residents were exiting and saw the door close and they walked up to the door and made sure it was secured. S6 stated that by the time they got to the door R1’s family had left. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff are serving food that does not meet individual needs, revealed the following. It was reported that the facility served R1 food that was unhealthy, high in salt and sugar and did not meet the needs of R1. A review of R1’s records show R1 was not prescribed a special diet. A review of the facility menu shows the facility is following Title 22 guidelines and the admission agreement which states that 3 nutritionally balanced meals along with snacks will be provided. LPA toured the kitchen and observed a two day supply of perishable food and a seven day supply of non-perishable food and observed all 4 food groups and observed fresh produce, dairy and proteins along with fresh bread and cereals. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 22-AS-20211013122800

Allegation investigated: Staff are not meeting residents needs Staff did not safeguard residents personal belongings

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Operations Specialist Rebecca Langdon and Exeuctive Director Lindsay Schroeder and explained the reason for the visit. The investigation into the allegation, staff are not meeting residents needs, revealed the following. It was alleged that Resident 1 (R1) was not having their hygiene and grooming needs met. It was reported that when visitors went to visit R1, R1 was not groomed and not completely dressed. No dates or times were provided as to when this incident occurred. The incident was reported to have, happened once. LPA interviewed the Director of Nursing who reported that R1 has their needs met and is dressed and groomed properly every day. It was reported that R1 is not being showered as often as needed. 5 out of 5 staff interviewed reported that R1 is showered twice or three times a week based on their need. Unsubstantiated The Director of Nursing reported that all residents are showered at least twice a week, but some residents require 3 showers a week and they are provided as needed. It was reported that R1 was not provided their incontinent briefs (briefs). 3 out of 5 staff reported that sometimes residents, including R1, take them off. 5 out of 5 staff reported that they attempt to have the residents put the briefs back on. 5 out 5 staff interviewed reported that they never force a resident to wear something they don’t want to wear. The Director of Nursing reported that they do their best to keep residents dressed but sometimes residents want to change their clothes or put something else on, and staff are instructed to assist residents and to make sure they are wearing clean clothing. 5 out of 5 staff interviewed denied the allegation and reported that all of the residents are being properly cared for. None of the evidence gathered supports the allegation therefore the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff did not safeguard residents personal belongings, revealed the following. It was reported that Resident 1’s (R1’s) bed sheets, hair dryer, handbag, clothes and coat went missing. No other specific details were provided. The Executive Director and Director of Nursing reported that no missing items were reported. 5 out of 5 staff members interviewed reported that they were unaware that R1 had any missing items. 5 out 5 staff reported that if a resident has missing bed sheets they replace them. The Director of Nursing reported that some residents provide their own sheets and all laundry for each resident is done separately so nothing goes missing. The Director of Nursing reported that if a resident’s sheets are being washed, clean sheets will be provided by the facility until their sheets are laundered and ready to be put on the resident’s bed. A review of R1’s inventory list shows R1’s responsible party declined to have any of R1’s property inventoried at the time of move in. It is unknown what items R1 moved in with and had in their possession. None of the evidence gathered supports the allegation, therefore the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided. Based on the evidence gathered, the preponderance of evidence standard has been met therefore the allegation is substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 22-AS-20220818123025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Oct 10, 2025

The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first... This requirement is not being met as evidenced by, R1's last care plan (reappraisal) was completed on January 3, 2023, which is 12 months and 2 weeks after the previous care plan (reappraisal) which poses a potential, health and safety risk to the Resident (R1).the state’s words, verbatim · CDSS document, Oct 1, 2025

Plan of correction: Licensee agrees to have staff responsible for completing care plans (reappraisals) trained on CCR 87463 and to submit proof of training to LPA by the POC due date.

Allegation investigated: Resident was left in soiled clothing Resident left with fecal matter in fingernails

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Executive Director (ED) Lindsay Schroeder and explained the reason for the visit. The investigation into the allegation, Resident was left in soiled clothing. No time or date of the incident was provided. R1 moved into the facility on December 7, 2021 and moved out of the facility on November 6, 2022. Witness 1 (W1) reported that when they visited R1 there was a strong smell of urine, and their clothes were soaked with it. W1 stated that they believed R1 was like that for hours. 5 out of 5 staff interviewed denied this report. The Executive Director reported that no one reported any issues with R1. The Wellness Director reported that no issues with R1 have been reported by staff or by any visitors. A review of R1’s records (progress notes) show no incidents occured to corroborate W1’s report. No evidence was gathered to support the allegation; therefore, the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. Unsubstantiated The investigation into the allegation, Resident left with fecal matter in fingernails, revealed the following. No time or date was provided as to when this occurred. R1 moved into the facility on December 7, 2021 and moved out of the facility on November 6, 2022. W1 reported that when they visited R1 they had fecal matter on/in their fingernails. No photographic evidence was provided. At the time of the initial visit R1 had moved out of the facility. W1 reported that R1's hands were probably like that for days. 5 out of 5 staff interviewed denied this report. The Executive Director reported that no one reported any issues with R1. The Wellness Director reported that no issues with R1 have been reported by staff or by any visitors. A review of R1’s records (progress notes) show no incidents to corroborate W1’s report. No evidence was gathered to support the allegation; therefore, the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Aug 13, 2025 · control 22-AS-20221107172314

Allegation investigated: Lack of supervision resulting in resident engaging in a physical altercation with another resident. Staff yelled at resident. Staff disturbing residents sleep.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Executive Director (ED) Lindsay Schroeder and explained the reason for the visit. The investigation into the allegation, Staff disturbing residents sleep, revealed the following. Resident 1 (R1) moved into the facility on June 10, 2021, and moved out of the facility on August 21, 2021. It was reported that Staff woke up R1 at 6:08 am for a temperature check and at 6:45 am for a shower. No dates were provided as to when these incidents occurred. Witness 1 (W1) reported that R1 told them about the shower at 6:15 am but they were not present at the facility when it took place. A review of records for R1 shows the facility did not perform any temperature checks on R1 that were documented. Staff interviewed reported they don’t do a temperature check unless instructed to by a doctor. Facility progress notes show that R1 was given a shower at 6:15 am on July 10, 2021. R1 has a history of getting up early, on August 7 6:20 am, July 27 6:45 am, June 26 6:30 am, June 24 Unsubstantiated 6:30 am, June 23 6:30 am, June 19 7:00 am, June 18 5:30 am, June 17 5:30 am and June 15 6:30 am. 5 out of 5 staff interviewed reported that R1 gets up early and will start to get ready for the day by showering or shaving on their own. Staff reported that when they see R1 is awake they will assist. The Wellness Director reported that no one has reported that staff are waking up residents early in the morning to shower them or take their temperature. R1 moved out of the facility prior to the visit. None of the evidence gathered supports the allegation therefore the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, Staff yelled at resident, revealed the following. It was reported on June 23, 2021, staff yelled at R1. Witness (W1) reported that R1 called them and then forgot to hang up the phone and they heard a staff member yell at R1, “get out of bed, shut the hell up”. No other evidence was provided to support the allegation. Staff 1 (S1), Staff 2 (S2) and Staff 3 (S3) who were present at the facility on the night of June 23 denied the allegation. S1 and S2 reported they assessed R1 that night and reported no one was yelling at anyone that night. S3 reported they did not hear anyone yelling that night. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation Lack of supervision resulting in resident engaging in a physical altercation with another resident, revealed the following. It was reported that a female resident (name unknown) agitated R1 and then another resident, Resident 2 (R2) provoked R1. R1 then pushed R2 who fell on the ground. W1 reported that this was because there was a lack of supervision. A review of records shows that on July 8, 2021, 2 staff were present assisting the residents (8). R1 had their own care companion. On July 8, R1 told R2, “No you can’t come in here”. Then R1 pushed R2. R1’s care companion attempted to break R2’s fall but R2 still fell to the ground. Staff 4 (S4) and Staff 5 (S5) who were present redirected R1 and assisted R2. 911 was called and R2 was transported to the hospital but returned the same day with no new orders and no injuries. R1 has been diagnosed with Dementia and on their physician’s, report is noted to have aggressive and wandering behavior. R1 does have a private care companion and staff immediately acted to redirect R1 and to assist R2. S4 and S5 reported they are always checking on residents to ensure their safety and redirecting residents when necessary. The facility has done what it can to minimize the risk to all residents concerning aggressive behavior and has not displayed a lack of supervision regarding this allegation. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided. The entire lobby including the See Something, Say Something Poster (PUB 475) is visible from the main facility hallway. Based on the evidence gathered the allegation is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The investigation into the allegation, Staff did not notify authorized representative of residents medical/medication changes, revealed the following. It was reported that the authorized representative/Responsible Party (RP) was not notified of any medical or medication changes. A review of R1’s records show that R1 did not undergo a change of condition while they were at the facility. R1 was prescribed 4 routine medications, Losartan, Omega 3, Vitamin D3 and Quetiapine. Vitamin D3 was added at R1’s RP’s request. Seroquel was changed to a PRN at the request of the RP. No other changes were noted in R1’s records. No specific details were provided as to what the RP was not notified of except for medical/medication changes. The medication changes were prompted by the RP and there were no medical changes reported. The facility did not have any medical or medication changes to report to the RP. Based on the evidence gathered the allegation deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided. Local Law Enforcement arrived and transported R1 back to the facility around 9:30 pm and staff assessed R1 and no injuries were noted. S1 and S2 verified this report. The ED reported that the staff have been trained on proper elopement protocol and proper supervision to verify the location of all residents to prevent elopement. According to R1's physician report they are not allowed to leave the facility unassisted. Based on the evidence gathered the preponderance of evidence standard has been met therefore the allegation is substantiated. Citation is being cited per Title 22, division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of the report along with the citation and appeal rights was provided to the facility representative.the state’s words, verbatim · CDSS document, Aug 13, 2025 · control 22-AS-20210823125938

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(e)(5) · Plan of correction due date: Aug 14, 2025

Care Of Persons With Dementia 87705(e)(5) Facility staff shall ensure the continued safety of residents if they wander away from the facility... This requirement is not met as evidence by: Resident 1 left the facility unattended on June 23, 2021 for approximately 30 minutes which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2025

Plan of correction: Licensee agrees to train all staff on elopement prevention training and to provide proof of training to LPA by the POC due date.

Allegation investigated: Staff did not provide adequate supervision, resulting in resident sustaining a fall

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Executive Director Lindsay Schroeder and explained the reason for the visit. The investigation into the allegation revealed the following. It was reported that Resident 1 (R1) fell June 22, 2025 and was found on the floor by Witness 1 (W1) and Staff 1 (S1). It was reported that a lack of staff led to R1's fall. Only the first name of R1 was provided. A review of records shows 2 residents (Resident 2 and Resident 3) have the same first name as the resident who was reported to have fallen (R1). LPA reviewed the staff schedule and 13 staff members worked on Sunday June 22, 2025. LPA reviewed the facility progress notes of Resident 2 and Resident 3, neither resident suffered a fall in June 2025. Only one fall was reported for June 2025 and it was for a different resident and is oocurred on June 9, 2025. No other falls were reported. There is one staff member (Staff 2) who has the same first name as the resident who was reported to have fallen. Staff 2 reported that on June 22, 2025 they fell and Staff 1 assisted them. Staff 1 verified this report. Witness 1 reported that they did not get a good look at the person who fell and did not know if it was a resident or staff member. Unfounded LPA attempted to interview Resident 2 and Resident 3 but neither resident responded to questions from the LPA. Based on the evidence gathered the allegation is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with the Administrator and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 30, 2025 · control 22-AS-20250623133915

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Executive Director (ED) Lindsay Schroeder and explained the reason for the visit. Lindsay Schroeder's Administrator's Certificate expires on January 1, 2027. Facility is a two story building with 2 courtyards (one on each floor) and surrounding parking lot. Facility is approved for delayed egress exits and a secured perimeter. LPA and ED toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the entry way of the facility. LPA observed the kitchen is clean and organized. There is a two day supply of perishable food and a seven day supply of non-perishable food on-hand in the kitchen. LPA observed that the refrigerators and the freezers had temperature logs posted on them. The refrigerators and freezers were at the required temperatures. LPA observed the facility has an ample supply of perishable and non-perishable food, but does not have a 3 day emergency supply of food. Facility does have a 3 day supply of emergency water. LPA and ED toured 6 resident rooms on the first and second floors. All resident rooms had the required furnishings and bed linens. All resident bathrooms were clean and operational. The hot water in the 6 resident rooms inspected measured between 109.0 degrees Fahrenheit to 112.6 degrees Fahrenheit. LPA observed residents watching a musical performance in the dining room. There is an activity room with games and puzzles and a TV room for residents. There is an outdoor courtyard on each floor with shaded seating for residents to sit outside. There are fire extinguishers on each floor and all fire extinguishers are fully charged. LPA observed an emergency evacuation chair at the top of the stairwell. The last emergency disaster drill was conducted on June 26, 2025. The delayed egress exits tested operational. The fire alarm/fire detection system was inspected and tested operational on April 5, 2024. LPA observed medications are kept secured in a medication cart that is locked in the medication room. LPA observed that the First Aid Kit had all the required elements. Facility has a dedicated computer with internet access for residents. LPA reviewed 5 staff files with no discrepancies observed. All staff files reviewed had the required annual training. All staff present at the facility are background cleared and associated to the facility. LPA reviewed 6 resident files. LPA inspected 6 resident medications. No discrepancies observed. No obstacles or hazards were noted inside or outside of the facility. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Jun 30, 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: Facility staff are not reporting incidents as required Staff are serving expired food to residents

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Adminsitrator Lindsay Schroeder and explained the reason for the visit. The investigation into the allegation, facility staff are not reporting incidents as required revealed the following. It was alleged that the facility did not report an incident with Resident 1 (R1) in which they suffered an unknown injury causing bruising under each eye. LPA interviewed the Administrator and 5 staff members. R1 did suffer an unknown injury. Facility staff reported the incident to the Responsible Party and the Primary Care Physician. The injury was first noted on March 4, 2025, On March 5, 2025 the injury was noted to be around both eyes. R1's nurse practioner (NP) saw R1 on March 7, 2025. R1 was not sent to the hospital. Resident R1 could not be interviewed because they did not respond to the LPA's questions. R1 suffered an unknown injury that was not reported to the Agency. Facility staff verified this report. Based on the evidence gathered the preponderance standard has been met therefore the allegation is substantiated. Substantiated The investigation into the allegation the facility serves expired food revealed the following. LPA toured the kitchen and inspected the food supply. LPA observed a two day perishable and a seven day non-perishable food supply on hand in the kitchen, LPA observed 12 cans of soup that expired on March 14, 2025. The kitchen staff disposed of the 12 cans of expired soup. LPA did not find any other expired food in the facility. LPA observed the kitchen is clean. Based on the evidence gathered the preponderance of evidence standard has been met therefore the allegation is substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.the state’s words, verbatim · CDSS document, Mar 25, 2025 · control 22-AS-20250317100336

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

(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 in (A) through (D) below. (D)Any incident which threatens the welfare, safety or health of any resident, This requirement was not met as evidenced by, staff reported R1 had an unknown that was not reported to the Agency, this poses a potential health, safety and/or personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Mar 25, 2025

Plan of correction: Licensee agrees to train staff on CCR 87211 reporting requirements and to submit proof of training to LPA>

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Apr 1, 2025

...All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not being met as evidenced by; LPA observed 12 cans of expired soup stored in the kitchen food storage area. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 25, 2025

Plan of correction: Licensee agrees to check all of stored food and to dispose of all expired food in the kitchen by the POC due date.

Allegation investigated: Facility did not provide requested documents.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Executive Director Lindsay Schroeder and explained the reason for the visit. The investigation revealed the following. LPA interviewed the Executive Director and witness 1. Witness 1 reported that the responsible party requested the facility records for Resident 1 (R1) on December 19, 2024 and the facility acknowledged the request but no records were provided. It was reported that on January 3, 2025 the facility was contacted again about the records request but the facility did not respond and as of January 22, 2025 no records have been received. The Executive Director verified this information and reported the document request was received and the document will be provided by January 28, 2025. Based on the evidence gathered through interviews the preponderance of evidence standard has been met therefore the allegation is substantiated. Deficiency is being cited per Title 22, division 6 of the California Code of Regulations. An exit interview was conducted, a copy of the this report (LIC809) along with the citation (LIC809D) and appeal rights was provided to the Executive Director. Substantiatedthe state’s words, verbatim · CDSS document, Jan 23, 2025 · control 22-AS-20250113121428

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(21) · Plan of correction due date: Jan 31, 2025

To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement was not met as evidenced by, Based on interviews the facility did not provide the requested documents within two business days, once requested. This poses a personal rights risk to residents.the state’s words, verbatim · CDSS document, Jan 23, 2025

Plan of correction: Licensee agrees to provide the records requested by January 28, 2025 and the Executive Director will sign a statement of understanding for the regulation HSC 1569.269, proof of completion to be submitted to the LPA by January 31, 2025.

Type of visit: POC

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a proof of correction visit for deficiency cited during the annual inspection. LPA was greeted and granted entry by staff. LPA met with Executive Director Lindsay Schroeder and explained the reason for the visit. LPA conducted a document review and obtained copies of resident physician reports. LPA verified the 2 residents who did not have a current LIC 602A (physician's report) that both residents have current updated physician's reports. The deficiency has been cleared. The Executive Director has been provided a proof of correction letter. LPA consulted with the Executive concerning reporting requirements and personal rights. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided to the Executive Director.the state’s words, verbatim · CDSS document, Sep 4, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted by staff and granted entry. LPA met with Executive Director (ED) Lindsay Schroeder and explained the reason for the visit. Lindsay Schroeder's Administrator's certificate expires on January 21, 2025. Facility is a two story building with 2 courtyards (one on each floor) and surrounding parking lot. No bodies of water observed. Facility is approved for delayed egress exits and a secured perimeter. LPA and the Executive Director toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the entry way of the facility. LPA observed the kitchen is clean and organized. There is a two day supply of perishable food and a seven day supply of non-perishable food on-hand in the kitchen. LPA observed that the refrigerators and the freezers had temperature logs posted on them. The refrigerators and freezers were at the required temperatures. LPA and ED toured 5 resident rooms on the first and second floors. All resident rooms had the required furnishings and bed linens. All resident bathrooms were clean and operational. The hot water in the 5 resident rooms inspected measured 111.2 degrees Fahrenheit to 114.4 degrees Fahrenheit. LPA observed residents watching a musical performance in the dining room. There is an activity room with games and puzzles and a TV room for residents. There is an outdoor courtyard on each floor with shaded seating for residents to sit outside. There are fire extinguishers on each floor and all fire extinguishers are fully charged. LPA observed an emergency evacuation chair at the top of the stairwell. The last emergency disaster drill was conducted on April 25, 2024. The delayed egress exits tested operational. The fire alarm/fire detection system was inspected and tested operational on February 13, 2024. LPA observed medications are kept secured in a medication cart that is locked in the medication room. LPA observed that the First Aid Kit had all the required elements. LPA interviewed staff and residents. LPA reviewed 5 staff files with no discrepancies observed. All staff files reviewed had the required annual training. LPA reviewed 5 resident files. LPA observed that 2 out of the 5 resident files (Resident 1 and Resident 2) did not have a current medical assessment (LIC602A). LPA inspected 5 resident medications. No discrepancies observed. No obstacles or hazards were noted inside or outside of the facility. Deficiencies are being cited per title 22 Division 6 of the California Code of Regulations on the attached LIC 809D. An exit interview was conducted with the Executive Director and a copy of the report provided along with appeal rights.the state’s words, verbatim · CDSS document, Jun 21, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit to follow up on an incident report (LIC 624) submitted to the Agency on June 5, 2024. LPA met with Executive Director Lindsay Schroeder and explained the reason for the visit. The incident report stated Resident 1 (R1) had an unexplained injury to their head. Staff reported there were no witnesses to the incident. Staff called 911, paramedics arrived and transported the resident to the hospital. The responsible party (RP) and R1's primary care physician (PCP) were notified. R1 returned to the facility the same day with no new orders. LPA interviewed staff and R1. LPA toured the dining room and R1's room. LPA observed no health concerns during the visit. No deficiencies observed during the case management visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided to the Executive Director.the state’s words, verbatim · CDSS document, Jun 21, 2024

Allegation investigated: Staff did not prevent a resident from developing a pressure injury while in care

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Executive Director (ED) Lindsay Schroeder and explained the reason for the visit. The investigation revealed the following. It was alleged that the staff did not prevent Resident 1 (R1) from developing a pressure injury while in care. R1 visited the hospital on April 8, 2024 and on April 13, 2024 due to falling. This information was verified through facility documents. On the hospital discharge paperwork for April 8, 2024 there is no mention of a pressure injury. The ED reported they did not receive any hospital discharge paper for the visit on April 13. The the facility notes for R1 do not mention of any pressure injuries. On April 3 the resident notes mention a red lump below the right hip and it will be monitored. On April 19 redness on the right hip area is noted and there is no wound opening. Staff interviewed reported that Home Health wound care was not ordered after either observation because the injury had not progressed to the level required for wound assistance. LPA attempted to contact the family of R1, LPA left a message but no contact was ever received. The facility notes show the staff assisted R1 with activities of daily living and provided care and supervision. Unsubstantiated LPA reviewed R1's physician's report (LIC 602A), needs and care plan, facility notes, hospital discharge paperwork, physician's orders and emergency contact information. R1 had no physician's order to be repositioned every two hours. There is no evidence that the staff caused any injury to R1. There is no evidence to verify that R1 had a pressure injury. LPA was unable to make contact with any of the witnesses except for facility staff. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, May 8, 2024 · control 22-AS-20240501101419

Allegation investigated: Facility did not provide resident's complete medical records to resident's authorized representative.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Executive Director Lindsay Schroeder and explained the reason for the visit. The investigation revealed the following. It was alleged that the facility did not provide all of the records for Resident 1 to the authorized representative after they were requested. The request for, "the complete chart" was received by the facility on February 21, 2024. On February 28, 2024 the facility emailed to the authorized representative of Resident 1, 147 pages, including the Admission Agreement, Physician's report and resident information. The Administrator verified that the information sent to the authorized representative did not include the Resident's medication administration records and resident notes. Based on the evidence gathered the preponderance of evidence standard has been met, therefore the allegation is substantiated. Citation is being cited per Title 22, division 6 of the California Code of Regulations. An exit interview was conducted, a copy of the this report along with citation and appeal rights was provided to the facility representative. Substantiatedthe state’s words, verbatim · CDSS document, Mar 11, 2024 · control 22-AS-20240301164328

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(21) · Plan of correction due date: Mar 18, 2024

(21)To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement was not met as evidenced by, the facility did not provide Resident 1's medication administration records and resident notes. This poses a potential health and safety risk to residents.the state’s words, verbatim · CDSS document, Mar 11, 2024

Plan of correction: Licensee agrees to have the Administrator provide a statement of understanding for the regulation HSC 1569.269 and to provide Resident 1's authorized representative their medication administration records and resident notes. Administrator to provide POC to LPA by POC due date.