Silverado Senior Living-Encinitas

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced case management visit to follow up on an incident report (LIC 624) received by Community Care Licensing (CCL) on August 19, 2026. LPA was greeted by Administrator Calais Anguiano, identified herself, and explained the purpose of the visit. The incident report indicated that Resident 1 (R1) sustained an unwitnessed fall at the facility on August 12, 2026, resulting in fractured ribs. Upon review of the incident report, CCL identified a potential concern regarding whether timely medical attention was sought following the incident. The LIC 624 indicated that R1 sustained an unwitnessed fall on August 12, 2026. An X-ray was ordered on August 15, 2026. The imaging results were received on August 16, 2026, and showed fractures to the seventh and eighth ribs. R1 was subsequently transported to a hospital by emergency medical personnel. R1 was not present at the facility during today's visit. During today's visit, LPA conducted a health and safety check, observed residents in care, reviewed facility records, and interviewed staff. During interviews, staff reported that the facility conducted an internal investigation, which resulted in the suspension of a staff member for not following established protocol for conducting appropriate and thorough assessments following a resident fall and for not seeking timely medical attention to meet R1's needs. (continue at LIC809C) (continue from LIC809) Based on the evidence obtained during the case management visit, a deficiency was cited pursuant to Title 22, Division 6, Chapter 8 of the California Code of Regulations and is documented on LIC 809-D. A plan of correction was developed with Administrator Calais Anguiano. An exit interview was conducted with Administrator Calais Anguiano. A copy of this report and the Licensee Appeal Rights (LIC 9058 3/22) were provided to the Administrator during the visit.the state’s words, verbatim · CDSS document, Sep 9, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(g) · Plan of correction due date: Sep 9, 2026

87465(g) Incidental Medical and Dental Care The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met, as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above. The licensee did not seek immediate medical attention for R1 after a fall, which posed a potential health and personal rights risk to 1 of 72 residents in care.the state’s words, verbatim · CDSS document, Sep 9, 2026

Plan of correction: Licensee suspended and is in the process of terminating the staff (S1) member as a result of the incident with R1. Licensee provided proof of S1's suspension and pending termination. The deficiency was cleared during LPA's visit.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ramin hashemi conducted an unannounced case management visit to conduct follow up regarding Incident reports received by Community Care Licensing. LPA was greeted by, identified themselves to, and explained the purpose of the visit with Joe Vasquez MSN, RN Sr. Director of Clinical Education. On June 12th, 2026, the Department received incident reports dated on June 10th and June 12th that the same resident had fallen multiple times with serious injuries. During today’s visit, LPA conducted a health and safety check, observed residents in care, reviewed facility records, interviewed residents and staff. No deficiencies were cited on today’s date. An exit interview was conducted with Joe Vasquez MSN, RN Sr. Director of Clinical Education, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Jun 15, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Receptionist Jeff Keast and Executive Director Calais Anguiano. The facility's license shows a maximum capacity of one-hundred-and-twenty-two (122) non-ambulatory residents. Additionally, the facility is approved for delayed egress, a secured perimeter, and a hospice waiver for twenty-five (25). During today’s inspection there were sixty-nine (69) residents in care. LPA, Executive Director Anguiano, and Director of Plant Operations (DPO) Josue Lopez toured the interior and exterior of the facility and inspected a sample of occupied and unoccupied resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. When testing the hot water at different sinks throughout the facility, water temperature consistently measured at around 97F. LPA had noted that all washing machines were in use in the laundry room, which could offset water temperatures in the building. Per DPO Lopez, laundry had been ongoing since 4am. LPA tested taps again later during the visit with an alternate thermometer and taps measured read at 112F. [Continued on LIC 809-C] [Continued from LIC 809] The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility features multiple secured outdoor spaces available for residents, with plenty of space and shady areas. Additionally, the facility features a variety of facility animals for therapy and companionship, including dogs, cats, birds, horses, and chinchillas. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. The kitchen contained a system to account for resident dietary needs and restrictions. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. A pool does exist on the premises and LPA observed that it was secured as required. A water fountain fixture is present in one of the outdoor courtyards accessible to residents, however it had been adjusted to not allow pooled water, thus mitigating risk to residents. Per Executive Director Anguiano, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months, dated for November 2025. Last staff fire frill was conducted on 1/24/26, for the topic of trash can fire. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Throughout the tour, LPA observed multiple resident activities taking place such as games, physical exercise, and socialization. While the facility does post a copy of resident rights at the front lobby desk, LPA offered a Technical Assistance (TA) to post more copies in the residential wings for ease of access for resident review. LPA interviewed two (2) staff and zero (0) clients, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Anguiano to whom a copy of this report, the LIC 9102 (TA) form, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Mar 19, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Executive Director Calais Anguiano, to discuss the purpose of the visit. Today's visit is in response to the facility's self report regarding Staff 1 (S1) utilizing an unauthorized self-release restraint on Resident 1 (R1) during incontinence care. Staff interviews, written staff statements, and facility documentation of the incident revealed that the facility had a "no restraint" policy, which was trained to all employees, including S1. The facility conducted an internal investigation regarding the incident; S1 informed that the intent of the restraint was to keep R1 from scratching themselves due to agitation while being provided care. Upon observation of the restraint by other staff, the situation was elevated to management and S1 was suspended immediately and subsequently terminated. An immediate medical examination was conducted for R1 by a licensed medical professional where no signs of trauma or injury were assessed for R1. All required parties were informed of the incident per reporting requirements. The investigation showed that the situation was elevated per the facility's chain of command and management took immediate action to rectify the incident. The investigation additionally revealed that the facility provided sufficient training to staff regarding appropriate postural support use and the prohibition of unauthorized restraints. S1 admitted knowing the facility's policy against use of restraints. LPA conducted a health and safety check for R1 at the facility; no health or safety issues were identified. A deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the Executive Director. An exit interview was conducted with Executive Director Calais Anguiano, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jan 2, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5) · Plan of correction due date: Jan 30, 2026

87608(a)(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. Based on records and interviews, Licensee’s employee (S1) restrained R1's hands during care. This posed an immediate personal rights risk to 1 of 78 residents in care.the state’s words, verbatim · CDSS document, Jan 2, 2026

Plan of correction: Licensee immediately suspended and subsequently terminated the staff in question, eliminating future risk. Executive Director agreed to conduct an in-service training for personal rights, specific to postural supports and restraints. Proof of training will be submitted to LPA by the POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Executive Director Calais Anguiano to discuss the purpose of the visit. Today's visit is in response to the self report of an allegation of physical abuse by a staff member toward a resident. The staff member was accused of striking a resident on the arm and preventing them from leaving their room. The facility corporate human resources department conducted an internal investigation, which was deemed unsubstantiated due to lack of evidence that the event occurred. The investigation included written statements from staff members who were present during the time of the allegation and witnessed the interaction between the accused staff and resident. The resident was assessed and found to have no markings or evidence that the incident occurred. The accused staff was placed on administrative leave pending the investigation outcome. LPA conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Executive Director Calais Anguiano, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Nov 25, 2025

Allegation investigated: Lack of supervision resulting in multiple injuries. Staff made false statements regarding resident incident. Staff falsified records

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced subsequent visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit and elements of the complaint to Executive Director Calais Anguiano. On 08/07/2025 it was alleged that staff’s lack of supervision for Resident 1 (R1) resulted in multiple injuries, staff made false statements regarding R1's incident, and that staff falsified records regarding R1's incident. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, outside sources, and records review. Regarding the allegation, “Lack of supervision resulting in multiple injuries”, eight (8) staff members involved in the incident on 08/02/2025 were interviewed. Staff interviews did not corroborate the allegation, as staff stated R1 had been supervised per care plan as routine, and was observed walking during and after dinner in their neighborhood of the facility. (Continued on LIC9099 p.2) Unsubstantiated (Continued from LIC9099 p.1) Staff stated that they began actively looking for R1 when R1 could not be located for their evening medication pass. Staff elevated R1’s absence per protocol through their chain of command, and R1 was located on the ground within the enclosed gated yard where residents were allowed to freely roam. Staff assessed R1 for injuries and notified R1’s Hospice agency as well as their Responsible Party. Staff additionally informed that the outside doors to the enclosed yard areas remained unlocked and open often throughout the day, per the facility’s “51 Standards” model for memory care residents. Staff stated unanimously that R1 did not have any physical injuries after the incident, with the exception of a possible minor cheek abrasion/redness. Staff stated they were unsure if the cheek abrasion was from the incident on 08/02/2025, or from a different injury due to R1’s pattern of frequent falls. Review of facility records corroborated staff statements regarding the timeline of events. The facility’s internal incident report and written statements from staff were consistent with staff statements made during interviews. Progress notes for R1 showed that R1 was placed on alert charting during the timeframe of concern and showed no signs of discomfort or pain after the incident occurred, vitals in normal range, and R1 presented at baseline. The facility’s “51 Standards” document stated that “Outside doors to enclosed yard areas are open every day and must remain open from 7:00am to 9:00pm”, corroborating staff statements that R1 was allowed to freely walk around the gated yard where they were found. Records did not give evidence that R1 was not being supervised according to their care plan during the time of incident. An outside medical professional familiar with R1 (OS1) was interviewed; OS1 informed that R1’s baseline was to walk around the facility for long periods during the day. OS1 additionally informed that due to cognition, R1’s walking pattern was absent of R1 looking down to see where they stepped, resulting in frequent falls. OS1 informed that a fall mitigation plan was in place with ongoing care plan updates between the facility, R1’s Responsible Person, and R1’s Hospice agency. OS1 informed that they frequented the facility due to being involved with multiple residents and did not have concerns regarding the facility’s supervision of R1 or other residents. A second outside source (OS2) from an advocacy agency was interviewed; OS2 informed that they had not conducted an investigation regarding the incident at the time of the call, however based on prior visits they had no concerns about supervision at the facility. (Continued on LIC9099 p.3) (Continued from LIC9099 p.2) During an unannounced facility visit LPAs Patterson and Ngallo walked the perimeter of the property; LPAs observed all gated yard areas to be enclosed and locked. LPAs additionally observed resident care in each neighborhood; LPAs observed residents being assisted by staff with activities of daily living (ADLS). No residents were observed to be waiting for care or in an unsafe or unsupervised location. LPAs attempted to interview R1, however due to R1’s major neurocognitive disorder they were not able to be qualified for interview. LPAs found observations of R1's gait and walking pattern to be consistent with staff and outside source statements. Regarding the allegations “Staff made false statements regarding resident incident”, and “Staff falsified records”, eight (8) of eight (8) staff members involved in the incident denied that they were instructed by management or another staff member to make false statements or omit information regarding R1’s incident, including written documentation of the incident. Staff informed that the interview statements and written statements were true and accurate to the incident. Each staff member was interviewed privately, and their statements/recollection of events were consistent with other staff statements and records. Two outside sources were interviewed regarding the allegations. The information provided by R1’s Hospice agency was consistent with the information provided by the facility. While OS2 had not yet conducted an investigation regarding the incident, they did not express concerns of the facility’s truthfulness regarding resident incidents. Review of facility records did not corroborate the allegations. Staff written statements and incident reports of the event corroborated verbal statements during interviews. Additional records revealed that an internal investigation was conducted by the facility’s Human Resources department, and no evidence was found that staff falsified details of R1’s incident or were instructed to do so. No records were found to give evidence to falsified statements or falsified records. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Calais Anguiano, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Oct 8, 2025 · control 08-AS-20250807121519

Allegation investigated: Staff mismanaged resident's medications.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced 10-day visit to initiate a complaint investigation and deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Calais Anguiano. On 07/01/2025 it was alleged that staff mismanaged Resident 1's (R1) medication. The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff, outside sources, and records review. Staff interview did not corroborate the allegation, as staff involved with medication administration informed no medication errors had occurred. Staff informed that a documentation discrepancy had ocurred but was corrected and the correct medication was given. Management informed that all medication errors are elevated and investigated, and confirmed that no medication errors had occurred for residents during the timeframe of complaint. Two outside sources were interviewed regarding the allegation. (Continued on LIC9099 p.2) Unsubstantiated (Continued from LIC9099 p.1) An outside protective agency familiar with the facility informed that they had not been made aware of any medication errors for the timeframe of complaint and did not have any concerns. An outside medical agency familiar with R1 informed that there have been no medication errors for R1 and no concerns about medication administration at the facility. Review of facility records did not corroborate the allegation. Progress notes for R1 showed that R1's prescription for a behavior condition was adjusted, resulting in them presenting as more lethargic than normal. R1 was placed on alert charting during the timeframe of concern, the notes showing that the new prescription was effective. Review of R1's Medication Administration Record (MAR) did not evidence that a medication error had occurred. No records were found to corroborate that a medication error occurred. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Calais Anguiano, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jul 3, 2025 · control 08-AS-20250701131855

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by concierge Caroline Fitzgerald. LPA discussed the purpose of the visit with Administrator’s Izzy Perez and Michelle Neumann and Kaitlyn Collins, Director of Resident and Family Services (DRFS). According to the facility’s license, there may be a maximum of 122 residents all of whom may be non-ambulatory in at any given time at the facility site with an approval waiver of 25 residents on hospice. Facility is approved for delayed egress and secured locked perimeters. During today’s inspection, the facility’s current census is 68 residents living at the facility. There were 68 residents present at the facility site during the inspection. LPA, accompanied by Administrator Neumann, DRFS Collins and Josue Lopez Director of Plant Operations, toured the interior and exterior of the facility, and inspected residents’ room. The facility was clean, sanitary and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required linens and furnishings. Doors, windows, toilets, and showers were all in working order. Extra linens and hygiene supplies are kept in the caregiver linen closet. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities. The facility’s ambient internal temperature was comfortable and compliant, at 74 degrees Fahrenheit (F). Hot water temperature at taps accessible to residents were compliant: In the Nexus Community, hot water temperature in a random room measured 108 degrees F; kitchen sink measured hot water at 107.8 degrees F; [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] In the Springs Community, hot water temperature in a random room measured at 111.9 degrees F; community sink measured hot water at 109.9 degrees F; the Pacifica Community, a random room measured hot water at 110.5 degrees F; community sink measured hot water at 112.8 degrees F; the Bluffs Community, a random room measured hot water at 111.7 degrees F; random room #2 measured hot water at 110.8 degrees F; and community kitchen measured hot water at 115.2 degrees F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present in their main kitchen. Cooking, dining equipment and utensils were present, and all safely stored in their storage area. There were no toxic chemicals or poisons accessible to residents. Medications were properly labeled, as required, and stored in their locked Wellness Centers. LPA inspected the medication room and found that medications were properly labeled and stored in a locked cart in their locked Wellness Center. The facility-maintained medication logs which LPA reviewed. The facility did have a pool area that measured up to 4 feet in depth. There was a locked gate that is in good repair which surrounded the pool. The fence was designed and installed to be unremovable and measured more than 5 feet high. The fence was not obscured from sight and there was no door or window which could access the pool area. The openings from the railings did not exceed 4”. The bottom from the ground to the hard surface of the fence did not exceed 2”. No ladder was observed near the vicinity of the pool and the platform is completely in accessible. The fence was thick enough that it could not be easily broken, removed or stretched. Administrator agreed that the fencing will remain in place and properly functioning whenever there are licensed residents in care. Administrator also agreed that ladders will remain inaccessible whenever there are licensed residents in care. Per Administrator Neumann, no firearms or ammunition are kept at the facility. Carbon monoxide detectors and fire alarms are yearly inspected by their Fire Department and was last inspected on March 10, 2025. Fire extinguishers were present (26) and serviced within the last 12 months. First aid kits were complete and readily accessible in their Wellness Centers. Emergency lighting and facility telephone were all working. LPA interviewed staff and residents, and reviewed staff and resident records. LPA interviews, with staff and residents, did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility. [CONTINUED ON LIC 809-C] [Continued from LIC 809-C] It should be noted that the inspection was interrupted for approximately one hour for a lunch break and resumed promptly at 1PM. During today's visit, there were no deficiencies observed or cited during the annual inspection. An exit interview was conducted with Administrator Michelle Neumann, Kaitlyn Collins, Director of Resident and Family Services, Keirstin Rodman, Clinical Staff and Office Manager, Kathy Roney, Culinary Director, and Cindy Blenkarn, Director of Health Services. A copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided to Administrator Neumann, at the conclusion of the visit. The signature below confirms the documents were received. LPA received their updated Plan of Operations to include the updated regulations for RCFE and Dementia. LPA requested Administrator Neumann to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, and Emergency Disaster Plan LIC 610-E to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.the state’s words, verbatim · CDSS document, Mar 28, 2025

Allegation investigated: - Facility did not allow resident to refuse medical care - Facility did not meet resident’s nutritional needs

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to open a complaint investigation. While at the facility LPA investigated and delivered findings regarding the above-mentioned allegations. LPA identified herself and was granted entry by Caroline Fitzgerald, Concierge. LPA stated the purpose of the visit and reviewed the findings of the complaint with Administrator Dyan Summerell and Kaitly Collins, Director of Resident and Family Services. The Department’s investigation consisted of interviews with staff and attempted interview with resident, records review of relevant documents pertinent to this investigation, and LPA observations. On February 28, 2025, it was alleged facility did not allow resident to refuse medical care, and facility did not meet resident’s nutritional needs. (Continuation on LIC9099-C) Unsubstantiated (Continuation of LIC9099) It was specifically alleged resident #1 (R1) had a catheter they did not want. Interview with the Executive Director, Diane Summerell, said they were following the R1s PCP orders upon admission. R1 ended up being discharged from the hospital with a catheter. They were aware R1 had ongoing issues with the use of the catheter but moved into the community with the catheter already in place. They did say that Home Health was coming out to assist R1 with their catheter. Per Executive Director, R1 currently does not have a catheter in place. Interview with staff #1 (S1) confirmed that the resident had the catheter in place when they had moved into the facility on or about December 10, 2024, but since has been removed. A review of records revealed that the hospital assessment, dated December 9, 2024, said a urinary retention Foley was placed. Hospital care plan, dated December 11, 2024, noted that resident had not made progress and recommended to address the barriers to include discharge with foley catheter. They did do a home health referral to CenterWell for PT and RN- foley care. Resident was admitted to the facility on or about December 10, 2024. According to R1’s preplacement appraisal, dated December 11, 2024, R1 had a new Foley at the hospital as they had failed their trial to remove it twice. Residents Physician’s report, dated December 3, 2024, showed the resident did have a Foley catheter. Home Health care notes show that they were assisting resident with their catheter about every 3 to 4 days since December 2024 through February 2023. Hospital discharge documentation, dated February 25, 2025, showed that R1 was sent to the hospital for displacement of Foley catheter. On March 7, 2025, LPA briefly spoke with R1, but was unable to qualify the residents interview. LPA observed that they did not have a catheter in place or bags on their person. Based on the aforementioned this allegation is deemed unsubstantiated. It was specifically alleged that the facility did not wake resident to have their meals. Interview with Executive Director Summerell said that the resident did come in with malnourishment. According to S1 the facility does have a Country Kitchen where they provide residents with many snacks if they are feeling hungry after meals. They are aware their caregivers are provided a list of residents to care for and assist them to their meals. According to S2, R1 is one of their good eaters. If they are asleep, S1 said they would hold on to their dinner plate and give it to them when they awake to have their dinner. At times R1 may be hungry throughout the night but is able to get a snack from their Country Kitchen. According to S3, they have worked with R1. S3 describes R1s eating customs to be a very well eater. They corroborated S2s statement, that they save residents food when its dinner time and the resident is sleeping. (Continuation on LIC9099-C) (Continuation of LIC9099-C) S3 said that it is not normal for R1 to be sleeping at dinner time but has occurred. R1 will also have all types of snacks if they are hungry. They go into their Country Kitchen and have a snack. A review of records revealed resident had a hospital visit prior to admission, dated November 21, 2024, and PCP serviced resident on November 22, 2024 that noted that resident’s appearance was an underweight elderly person. The hospital assessment noted that the resident had moderate to severe malnutrition. On November 30, 2024, the resident was seen at the hospital, and their assessment regarding the resident’s weight did not change – the resident was still underweight. An email dated December 10, 2024, from the facility did make staff aware R1 did have a malnourishment diagnosis with significant weight loss upon R1s admission. Hospital progress notes dated December 7, 2024, said the resident had an appetite that day and weighed 51.2 kilograms (approximately 112.87 pounds) for their last 10 readings. Facility weight notes show that the resident has been fluctuating in weight between 113 – 120 pounds the past month. The facility is obtaining Nutritional Care Notes from Dining which indicate R1s diagnosis, weight, plan and goal to address their condition. During LPA’s visit on March 7, 2025, they saw R1 was in the activities room with a peanut butter and jelly sandwich and a water and had another before LPA left. Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff interviews, records reviewed, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be unsubstantiated. The report was discussed and an exit interview was conducted with Executive Director Dyan Summerell and Kaitlyn Collins, Director of Resident and Family Services. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Summerell at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Mar 7, 2025 · control 08-AS-20250228165315

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced visit to open a complaint investigation and in conjunction conducted this case management visit. LPA Lopez identified herself and was granted entry by concierge Jeffrey Keast. LPA Lopez stated the purpose and reviewed basic elements of the case management visit with Cindy Blenkarn, Director of Health Services (DHS). On 02/20/2025, the Department received a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) for resident #1 (R1 – see Confidential Names List). According to DHS Blenkarn, the SOC341 was not the formal notice of eviction but a notification that one will be forthcoming. LPA reviewed Title 22, Division 6, Chapter 8, Article 4, Sections 87224 Eviction Procedures with Director of Health Services Blankarn, and the records to submit alongside the notice. No deficiencies were cited during this visit. An exit interview was conducted with Administrative Specialist Sabrina Pegros, Executive Director Dyan Summerell, and Director of Health Services Cindy Blenkarn. A copy of this report along with the Licensee Rights (LIC9058 03/22) were provided to Administrative Specialist Sabrina Pegros at the conclusion of the visit. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, Feb 20, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to initiate a case management visit. LPA Lopez identified herself and was granted entry by concierge Jeffrey Keast. LPA Lopez stated the purpose of the visit and reviewed the basic elements of the visit with Executive Director Marivel Johnson and Administrative Specialist Sabrina Pegross. This visit is in response to an Unusual Incident/Injury Report (IR) that was received at the San Diego Regional Office on October 2, 2024. The IR stated that there was an incident that transpired on Tuesday, September 24, 2024, with resident #1 (R1 – see LIC811 for confidential names list) who eloped from the facility. The facility made notifications to R1’s responsible party, their Medical Doctor (MD), and the Department. During today's visit LPA Lopez briefly toured the facility, spoke with staff and R1, and requested and obtained relevant documents pertinent to this incident. LPA Lopez verified R1 eloped from the facility, but staff found R1 within about 15 minutes from notification that R1 was absent without leave (AWOL). Records showed that a wander guard was placed on R1 on 09/25/2024. R1’s service plan was updated on 09/23/2024 and on 09/24/2024 to include monitoring and elopement. Preplacement Appraisal did not indicate R1 had issues with elopement prior to admission. According to interviews R1 attempted to leave the facility once formerly, on Monday, 09/23/2024, but staff was always with R1 and they walked around the facility until R1 was ready to walk back in to the facility prior to the incident on 09/24/2024. The incident on 09/24/2024 was R1’s first AWOL from the facility since their move to the facility. Staff interviewed said they had assigned locations as to where they needed to look. Some staff drove around while others walked to the nearest locations in search of R1. R1 was found within the vicinity of the community unarmed within minutes of notifications being made. (Continuation on LIC809-C) (Continuation of LIC809) R1’s Elopement Plan states that if a resident, such as R1, is not found within the initial sweep of the community and immediate surrounding area, notifications should be made to the local police, residents’ physician and responsible party. R1 was found within the vicinity of the community about 15 minutes after notifications were made that the resident was missing. Associates may be assigned to drive around the area. In review of the procedure and staff interviewed, the facility’s elopement procedure was followed. No deficiencies were cited during today’s visit. LPA informed Administrative Specialist Sabrina Pegross that there may be possible follow-up telephone calls or visits for this incident. An exit interview was conducted with Administrative Specialist Sabrina Pegross, and a copy of this report, LIC811 and Licensee Appeal Rights (LIC9058) were provided at the conclusion of the visit. The signature below confirms that the documents were received.the state’s words, verbatim · CDSS document, Oct 3, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to initiate a case management visit. LPA Lopez identified herself and was granted entry by concierge Jeffrey Keast. LPA Lopez stated the purpose of the visit and reviewed the basic elements of the visit with Executive Director Marivel Johnson and Administrative Specialist Sabrina Pegross. This visit was in response to an Unusual Incident/Injury Report (IR) that was received at the San Diego Regional Office on September 20, 2024. The IR stated that there was an incident that transpired on Wednesday, September 18, 2024, with resident #1 (R1) who mentioned that they were assaulted but no person was identified. The facility made proper notifications to law enforcement, Long Term Care Ombudsman (LTCO), residents responsible party and to the Department. During today's visit LPA Lopez briefly toured the facility, spoke with staff and R1, and requested and obtained relevant documents pertinent to this incident. LPA Lopez verified R1 had delusions when the allegations were made. According to records R1 does have an underlining condition of hallucinations. Additional records showed that R1 was diagnosed with an infection which altered R1's behavior and baseline. LPA informed Executive Director Marivel and Administrative Specialist Sabrina Pegross that there may be possible follow-up telephone calls or visits for this incident. No deficiencies were cited during today’s visit. An exit interview was conducted with Executive Director Marivel Johnson and Administrative Specialist Sabrina Pegross, and a copy of this report, LIC811 and Licensee Appeal Rights (LIC9058) were provided at the conclusion of the visit. The signature below confirms that the documents were received.the state’s words, verbatim · CDSS document, Oct 2, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to initiate a case management visit. LPA Lopez identified herself and was granted entry by concierge Carolyn Fitzpatrick. LPA Lopez stated the purpose of the visit and reviewed the basic elements of the visit with Director of Health Services Cindy Blenkarn. Executive Director Marivel Johnson later arrived and joined the visit. This visit was in response to an Unusual Incident/Injury Report (IR) that was received at the San Diego Regional Office on August 20, 2024. The IR said that there was an incident that transpired on Tuesday, August 13, 2024, with resident #1 (R1) and resident #2 (R2) in the kitchen area. Neither R1 nor R2 sustained any injuries during this altercation. During today's visit LPA Lopez spoke with staff and resident's, toured the facility, and requested and obtained relevant documents pertinent to this incident. LPA Lopez verified that the facility kitchen area that the incident occurred at, is a communal kitchen that is adjoined with an activities area that all residents are able to have access to. LPA informed Executive Director Marivel Johnson that there may be further follow-up telephone calls or visits for this incident. An exit interview was conducted with Executive Director Marivel Johnson, and a copy of this report, LIC811 and Licensee Appeal Rights (LIC9058) were provided to ED Johnson at the conclusion of the visit. The signature below confirms that the documents were received.the state’s words, verbatim · CDSS document, Sep 6, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to initiate a case management investigation. LPA Lopez identified herself and was granted entry by concierge Caroline Fitzgerald. LPA Lopez stated the purpose of the visit and reviewed the basic elements of the visit with Executive Director Marivel Johnson. This visit was in response to an Unusual Incident/Injury Report (IR) that was received at the San Diego Regional Office on Monday, May 6, 2024. The IR said that there was an incident that had transpired on Tuesday, April 30, 2024, with resident #1 (R1) who sustained injuries. During today's visit LPA Lopez spoke with staff and requested and obtained relevant documents pertinent to this incident. LPA Lopez verified the facility staff who found resident and made contact with their nurses. The facility staff who arrived at the scene contacted the nurse who then called paramedics who transported the resident to the hospital where resident was seen. LPA informed Executive Director Marivel Johnson that there may be further follow-up telephone calls or visits for this incident. LPA requested for Executive Director Johnson to submit a death certificate upon receipt to LPA Lopez. An exit interview was conducted with Executive Director Marivel Johnson, and a copy of this report, LIC811 and Licensee Appeal Rights (LIC9058) were provided to ED Johnson at the conclusion of the visit. The signature below confirms that the documents were received.the state’s words, verbatim · CDSS document, May 7, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection. LPA Rodgers were granted entry into the facility by Administrator Marivel Johnson after identifying herself and stating the purpose of the inspection. The facility serves elderly residents, age 60 and above, 122 whom may be non-ambulatory. There is an approved Hospice Waiver for 25 residents. LPA was accompanied by Administrator Marivel Johnson for a tour of the facility which was conducted inside and out and included a sample of resident units, the dining area and recreation rooms. There is a fire signal system in place and the carbon monoxide detectors were operational. The last disaster drill was conducted on January 2024. Exterior and interior passageways were free from obstructions. Pull cords, tab alarms alerts as well as pendants are present in the facility. The facility Resident rooms and facility room temperatures were within a comfortable range. There are locked interior and exterior doors throughout facility. LPA observed a pool on the premises that is used for group activities, the pool is properly secured with a fence and a locked gate to enter from the outside area, the facility doors that give lead to the pool area are all equipped with keypad locks that require a combination for access. Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. [Continued on 809-C] [Continued from 809] Facility has a two-day supply of perishable and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closet. The medication carts were locked and stored in the medication rooms. Medications were labeled and kept in compliance with label instructions. LPA interview confirmed the licensee provides assistance in meeting medical and dental needs. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA also conducted a review of In-service training procedures. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance There is designated art/craft room, garden activity patio along with gathering areas throughout the facility. At the time of visit, LPA observed several large group activities that include pet therapy. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No deficiencies were sited at the time of visit however, a technical violation was issued. A final exit interview and a copy of this report, Licensee/Appeal Rights - LIC 9058 (rev. 01/16), LIC9102TV were provided to , Administrator Johnson whose signature on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Feb 29, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: - Facility employed staff without background clearance

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to open a complaint investigation. While at the facility LPA investigated and delivered findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by Marisa Hatcher, Business Office Coordinator. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director Marivel Johnson. The Department’s investigation consisted of interviews with staff, and records review of relevant documents pertinent to this investigation. On October 6, 2023, it was alleged that the facility employed staff without a background clearance. It was specifically alleged that between June 2023 through October 2023, the facility did not obtain appropriate criminal background clearance for staff. Interview with staff said the facility received an exemption letter from the Department after a staff was cleared to work around June 2023. Substantiated After staff read the letter, staff was unclear and unsure who would need to process the exemption, staff or the facility. The letter was received July 2023. Staff confirmed that the staff person worked at the facility after the exemption was received, from July 2023 – October 2023. A review of staff records revealed that the facility received the exemption letter July 2023. The letter does inform the facility that the individual was disqualified from obtaining a background clearance. A review of staff schedules confirmed that the staff worked between the months of July 2023 through October 2023, at the facility. On October 13, 2023, LPA observed that the staff was not present at the time of the investigation. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff interview, records reviewed, and LPA observations, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Administrator Marivel Johnson. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Johnson at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Oct 13, 2023 · control 08-AS-20231006152308

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87355(e)(3) · Plan of correction due date: Oct 27, 2023

87355 (e)(3) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing, or volunteering in a licensed facility: (3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. … this requirement was not met as evidence by: Based on interviews and records reviewed, staff did not obtain an approved criminal exemption request prior to continue working at the facility. This posed a potential safety risk to 77 of 77 residents in care.the state’s words, verbatim · CDSS document, Oct 13, 2023

Plan of correction: Administrator will conduct training with staff regarding all exemption requests and clearances sent forth by the Department by POC due date, 10/27/23.