Signature Living on Camelia Avenue

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 11/25/25 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. House manager, Jacob, assisted with the visit. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA discussed deep cleaning of the kitchen, R2's blinds replacement and dresser knobs, and the condition of the property fence. Facility records review found absence of quarterly emergency drills. LPA reviewed 3 resident and 2 staff files. Files were complete for residents. Staff training on file was insufficient. LPA requested the following documents to update the facility file: Liability insurance and LIC 500. As a result of this inspection, deficiencies are cited. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Exit interview conducted with Ayunasia "Jacob" Sogari and copy of report and appeal rights left at the facility.the state’s words, verbatim · CDSS document, Nov 25, 2025

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff are mismanaging resident's medication Staff are not meeting resident's dietary needs

On 10/22/25, Licensing Program Analyst (LPA) Kevin Mknelly spoke to caregiver, designee to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records and conducted interviews. LPA finds that the allegations cited above are substantiated. For a period of time there was some confusion and inconsistencies regarding an ointment and cream regiment for a wound to R1's head that lead to R1 not receiving medications as prescribed. The orders have since been clarified and the situation is resolved. R1 has a physician's order for a high protein diet for healing wounds that have been present at admission. Facility staff did not have a written plan to ensure protein intake and integrated R1's food preferences. A written plan is now in place and R1's preferences are accomodated. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed withdesignee . Copy of this report and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Oct 22, 2025 · control 59-AS-20250813104454

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 23, 2025

Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed.This requirement was not met for R1 based on records and interviews. This posed a potential risk to R1.the state’s words, verbatim · CDSS document, Oct 22, 2025

Plan of correction: At this visit, LPA observed that R1 is receiving medications as prescribed. POC cleared by visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(7) · Plan of correction due date: Oct 23, 2025

General Food Service Requirements (b) (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met for R1 based on records and interviews. This posed a potential risk to R1.the state’s words, verbatim · CDSS document, Oct 22, 2025

Plan of correction: At this visit, LPA observed that R1 is receiving required and preferred foods as prescribed. POC cleared by visit.

Allegation investigated: Staff do not ensure resident is provided incontinence care in a timely manner

On 5/1/25, Licensing Program Analyst (LPA) Kevin Mknelly spoke to caregiver and house manager (by phone) to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records and conducted extensive interviews. LPA interviewed R1 during this visit. LPA finds that the allegations cited above are substantiated. Statements by R1 and caregivers found that there had been a prior incident where R1 had incontinence and the caregiver present was not able to do incontinence care alone. The other staff for the shift had checked with R1 before leaving for a break and R1 did not have a care need. While that staff was on break, R1 experienced incontinence. The incontinence care was provided when there were two staff present. This caused a delay in R1's care. The facility has since made changes to staff scheduling and there have been no further incidents. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with caregiver . Copy of this report and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, May 1, 2025 · control 59-AS-20250225091336

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625 · Plan of correction due date: May 2, 2025

Managed Incontinence (b)(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met based on statements by resident and staff. This posed a potential risk to R1.the state’s words, verbatim · CDSS document, May 1, 2025

Plan of correction: The licensee has corrected this situation by instituting scheduling changes to ensure adequate number of qualified staff are present for resident needs. This POC is cleared by this visit.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 10/23/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator was unavailable to assist. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home is very clean and residents stated they are happy with care. LPA provided advisories regarding various topics. Citations issued for documentation of emergency training and drills. LPA reviewed 6 resident files. Files are complete and well organized. LPA advised more thorough Needs and Services and Home Health care plans. PIN 22-24-ASC provided. LPA reviewed 2 staff files. Increased training documentation needed Deficiencies are being cited as a result of todays inspection. Exit interview conducted with Caregiver. Due to Printer malfunction, copy of report and appeal rights are to be emailed to Licenseethe state’s words, verbatim · CDSS document, Oct 23, 2024

Type of visit: Case Management - Deficiencies

On 1/19/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with designee, Shenel Phang . LPA spoke with Administrator by phone regarding the report and findings. On 12/14/23, LPA Mknelly, conducted a visit and issued a citation based on the information available at the facility at the time regarding an incident report received by the department on 12/12/23. The 12/12/23 incident report was regarding a hospital visit for R1 on 12/7/23. LPA conducted a records review regarding R1. Records found that R1 was admitted to this facility on 10/25/23. Discharge instructions from the referring hospital identified R1 as having wounds that require daily ongoing wound care. Between 10/25/23 and 12/7/23 R1 did not receive home heath wound care at the facility. Following the 12/14/23 visit, LPA Mknelly collected the following additional records regarding R1’s wounds care history: referring hospital wound care and discharge status of wounds, area hospital records for 12/7/23- 12-9/23, and current home health records. Referring hospital wound care records, received from the hospital by LPA on 1/11/24, showed that on 10/25/23, R1 was transferred to this facility with a stage IV Sacrococcygeal pressure injury, a Full thickness (non- pressure) injury to left thigh, contractures requiring continued physical therapy. Report continued... 10/25/23 discharge instructions recommended daily dressing changes to the Sacral and sacrococcygeal pressure injuries and dressing change to the left thigh wound every other day. An appointment for a tele-health follow-up call on 1/30/23. Licensee did not present a record that the 10/30/23 tele-health call occurred. R1’s LIC 602- physician’s report, dated 9/19/23, noted non-healing wounds. R1’s LIC 625- Appraisal Needs and Services Plan, dated 11/29/23, listed severe deformity and contractures requiring exercise. There was no wound care plan developed. On 12/7/23- 12/9/23 area hospital records noted: HISTORY OF PRESENT ILLNESS: (R1) brought in by ambulance sent to the emergency department by board and care facility for wound check. Patient reports (R1) is worried for infection as (R1) was just admitted into the hospital one month ago for chronic pressure wounds to his coccyx, elbows, and lower extremities. (R1) is concerned for infection and states the wound to his left lower extremity is more red and starting to become black. Emergency department diagnosis: Pressure ulcer of sacral region, unspecified stage; Pressure ulcer of left hip, unspecified stage; Pressure ulcer of right hip, unspecified stage and Abrasion of scalp, initial encounter. R! was admitted for wound care evaluation and for case management to discuss resources for discharge planning. On wound care evaluation patient was found to healing pressure ulcers to sacrum and bilateral hips as well as healing open wound to left anterior thigh unclear etiology as well as abrasion to posterior scalp again of unclear etiology. R1 returned to the facility on 12/9/24 with orders for Home Health which began on 12/10/24. Home health records showed that on 12/22/23 R1 was assessed to have two (2) stage III pressure injuries. One to the coccyx and to low right buttocks. (Note: the buttocks pressure injury was no noted at discharge from the referring hospital.) The injuries were explicitly identified to facility staff. Staff, Nerryrose Kreig , who was informed by Home Health, did not take immediate action to request and exception from licensing or to have R1 seen at a hospital until 1/2/23, at the prompting by LPA Mknelly, for this prohibited health condition. ER doctor determined that R1’s wounds were stage II or less and R1 returned to the facility with continued Home Health Wound care. Therefore, medical records review found that in addition to the citation issued on 12/14/23 for a lack of a wound care plan for R1, R1 was admitted and knowing retained at the facility with prohibited conditions of Stage III and IV pressure injuries. Those healing wounds were also neglected by facility staff between 10/25/23 and 12/7/23 which severely risked R1’s health and safety. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on health and safety code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Jan 19, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Jan 22, 2024

Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met based on records review which showed R1 was admitted to the facility with stage IV injuries. This posed an immediate risk to resident health and safety.the state’s words, verbatim · CDSS document, Jan 19, 2024

Plan of correction: R1 is currently stable and receiving appropriate care. Licensee will submit proof of scheduled training for preappraisals and prohibitted conditions to CCL by the POC date of 1/22/24. Scheduled training must be completed within 30 days from this date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(a)(1) · Plan of correction due date: Jan 22, 2024

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility…by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met based on records review and statements that found R1 had recommendations for wound care that were not arranged for by the licensee. This posed an immediate risk to the resident. Civil Penalties are applied.the state’s words, verbatim · CDSS document, Jan 19, 2024

Plan of correction: R1 is currently stable and receiving appropriate care. Licensee will develop procedures to address, staff knowledge of resident conditions, staff observation for changes to known conditions and response, up to call to 9-1-1, when resident conditions need medical care. Procedure will include staff training. Procedure to be submitted by the POC date of 1/22/24.

Type of visit: POC

On 12/20/23, Licensing Program Analyst (LPA), Kevin Mknelly, conducted a plan of correction visit (POC) inspection for deficiencies issued on 12/14/23. LPA was greeted by caregiver. On 12/14/23 deficiencies were cited for failure to provide for wound care as needed for R1. Licensee has not submitted the POC for the citation that was due by 12/15/23. LPA spoke by phone with Nerryrose Kreig, designated responsible staff, and explained that civil penalties are being issued and that the plan of correction continues to be due. LPA also met with R1. R1 stated they are receiving regularly scheduled Home Health and that care at the home is meeting their needs. No additional deficiencies are cited for today's visit. An exit interview was conducted with caregiver. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 20, 2023

Type of visit: Case Management - Incident

On 12/14/23, Licensing Program Analyst (LPA) Kevin Mknelly, met with facility staff to conduct a case management visit. LPA was following up on an incident report received by the department on 12/12/23. The report was regarding a hospital visit for R1 on 12/7/23. LPA conducted a records review regarding R1. Records found that R1 was admitted to this facility on 10/25/23. Discharge instructions from the referring hospital identified R1 as having wounds that require daily ongoing wound care. Between 10/25/23 and 12/7/23 R1 did not receive home heath wound care ar the facility. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Dec 14, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87631(a)(1) · Plan of correction due date: Dec 15, 2023

Healing Wounds (a), the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances: (1) When care is performed by or under the supervision of an appropriately skilled professional. This requirement was not met based on records review and interviews. This posed and immediate risk to the resident.the state’s words, verbatim · CDSS document, Dec 14, 2023

Plan of correction: Licensee will submit a wound care plan for R1, which includes but is not limited to: Staging of R1's current wounds, schedule for home health, training of caregivers, reposition schedule if ordered and a communication system to record wound care performed at every home health visit. This POC is due 12/15/23 by 5PM.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 11/29/23 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator arrived to assist. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. Advisories issued. The home is very clean and residents stated they are happy with care. Water temperature exceeded 125' F. LPA reviewed 6 resident files. Files are complete and well organized. Two resident files missing admission agreements and and appraisals. LPA reviewed 2 staff files. Files are complete. Advisories issued for documentation of training for restricted conditions. Licensee will submit LIC 9020, LIC 500, current facility sketch, training records for R2 (from other facility) and new Liability Insurance certificate. Deficiencies are being cited as a result of todays inspection. Exit interview conducted with licensee and copy of report left at the facility.the state’s words, verbatim · CDSS document, Nov 29, 2023

The state marks this report as 11 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.