Silverado Senior Living-Sierra Vista

Allegation investigated: Staff member worked while under the influence of alcohol, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care.

Licensing Program Analyst (LPA) Tao conducted an unannounced 10-day complaint visit to the facility. Upon arriving at the facility, LPA met with Administrator Vida Gwinn. LPA explained the purpose of today’s visit and discussed the allegation with Administrator Gwinn. The investigation consisted of six (6) resident interviews, eight (8) staff interviews, physical plant tour, and facility records reviews of the obtained records, including resident roster, staff roster, staff#4 (S4) Personnel Record, S4’s annual review, Human Resource email correspondence, Handbook on Alcohol and Substance Abuse Policy, FMLA/Leave of Absence Claim, and Employee Assistance Program (EAP). The investigation revealed the following: (-continued on LIC 9099C-) Unsubstantiated Regarding allegation: Staff member worked while under the influence of alcohol, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care. It is alleged that a staff was drunk at work which impaired the staff’s ability to provide care and supervision and present a risk to residents. Per resident interviews, six (6) out of eight (6) interviewed could not corroborate the allegation. Per staff interviews, all eight (8) staff interviewed could not corroborate the allegation. The staff interview revealed that no staff were observed to be drunk on the job. The incident of staff who was under the influence of alcohol occurred outside of the facility after work hours. Per record review, the alleged staff had a very minimal interaction with residents due to staff’s job nature. The facility policy has zero tolerance on alcohol and substance abuse. Per Administrator's interview, Administrator Gwinn would provide professional psychological support, consultation and Employee Assistance Program (EAP) to staff who need the support. The facility would follow up with the staff and be more aware of staff’s psychological well-being. Based on the information obtained during the investigation, interviews with staff and residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator Vida Gwinn. The findings were discussed and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 21, 2026 · control 28-AS-20260820112700

Allegation investigated: Staff are limiting resident's visitor time

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced complaint investigation to investigate the above allegation. LPA met with Administrator Vida Gwinn and Selene Rangel, DHS (Director of Health Services). LPA explained the purpose of the visit. The investigation consisted of the following: LPA requested Resident and Staff rosters, obtained copies of relevant documentation, interviewed Administrator, Staff 1 (S1) - Staff 3 (S3), Resident 1 (R1) - Resident 8 (R8). Continue 9099C Unsubstantiated The investigation revealed the following: Regarding allegation: Staff are limiting resident's visitor time. It was alleged that facility staff limited R1's visitation time by one hour per week. Interviewed Administrator and staff stated that facility allows visitation with family members and friends and facility encourages these visits. They stated that visitors are welcome at any time and for residents security, visitors must register at the front desk when entering the Community and sign out when they leave. LPA reviewed the facility’s visitor policy which states that residents have the right to visitors in which residents are able to have visitors of their choosing at any time. Interviewed Administrator and staff mentioned that facility staff are aware of who the Responsible Party (RP) / Power of Attorney (POA) for each resident and per their request visitation hour can be changed, limited or restricted if there is restriction order from the court. Interviewed Administrator and staff stated that for R1 there is a visitor (V1) who's visitation hours were limited by R1's POA. They stated that V1's visitation hours are limited to one time per week for one hour. POA made this decision after R1 was observed agitated and emotionally distressed after V1's visits. LPA reviewed emails between Facility and R1's POA. It says " V1's presence and poor behavior and choice of unpleasant and negative talking points has clearly contributed to R1's agitation and emotional distress...additionally V1 placed a tracking device in R1's purse which is unacceptable. I demand that Silverado medical and care team limit V1's visits to one supervised visit per week, for one hour, on Wednesdays and any request to change the visitation day will be made at least one week in advance....". Interviewed Administrator and S1 stated that V1 was aware that R1's POA would only like V1 to visit once a week per hour and on occasions when V1 has stayed longer than one hour they has been asked to leave. Interviewed Administrator mentioned that R1 was observed to be tired in the long visits V1 that R1 would tend to refuse their meals and would not participate in activities. Also gets more easily upset at times when V1 is around and talks to R1 about "escaping", going home. Interviewed S1 stated on 04/15/26 at the time of visit, V1 was making statements to R1 that they will "kidnap" R1 during the visit. V1 was notified that their visit was only 1 hour due to past visits history, that V1's comments and suggestions caused emotional distress and agitation to R1. Continue 9099C V1 has been asked to leave by S1 a couple of times due to R1 being noted as anxious and at times refusing a meal after V1's visits (Notes were provided to LPA). Interviewed S2 stated that on 04/15/26 they received phone call from R1's POA and notified that V1 would be coming to visit and advised that V1 has only 1 hour to visit R1 and does not allow to take R1 out of Community. S2 indicated that email was sent to facility leadership team. LPA interviewed 8 residents and they stated that they are allowed visitation with family and friends and they can visit them at any time without limitations. Based on records review and interviews conducted with facility staff and residents although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.the state’s words, verbatim · CDSS document, Apr 21, 2026 · control 28-AS-20260416085517

Allegation investigated: Staff did not supervise the resident according to their needs. Resident sustained unexplained scratches their back. Staff did not administer medication as prescribed. Staff allowed the resident to be malodorous. Staff left the resident soiled. Facility did not provide a refund.

Licensing Program Analyst (LPA) Nune Margaryan conducted a subsequent unannounced complaint visit to deliver finding to the above-mentioned allegations. LPA met with Selene Rangel-Gutierez. LPA explained the reason for the visit. The investigation consisted of the following: During the initial visit, on 09/23/25 LPA Nune Margaryan obtained copies of Staff & Residents rosters, interviewed Administrator, Staff 1 (S1) - Staff 5 (S5), Resident 2 (R2) - Resident 8 (R8) and requested Resident 1's (R1) file. LPA reviewed and collected documents related to R1. LPA was unable to interview R1. R1 was moved from the facility on 09/10/25. Continue 9099C Unsubstantiated Regarding allegations: Staff did not supervise the resident according to their needs and Resident sustained unexplained scratches their back. It was alleged that staff allowed the resident to wander without supervision and scratch themself, resident sustained unexplained scratches to their back. The Administrator and staff were interviewed and denied the allegation. They stated that residents are supervised at all times based on individual needs and that adequate supervision is consistently provided. Staff reported that R1 required full hands-on assistance with all activities of daily living, including meal setup with guidance and reminders, as well as incontinent care. Staff further stated that R1 had a history of sensitive skin with intermittent skin issues. According to staff, lotions and ointments prescribed by R1’s physician were applied daily per doctor’s orders, even when skin irritation was not present. Staff stated they did not observe any new scratches or marks on R1’s skin prior to R1 moving out of the facility. The LPA reviewed R1’s file and confirmed that skin treatments were administered in accordance with the physician’s orders. Records indicated that on the day R1 was picked up by the responsible party, R1’s skin was clear, intact, and free of lesions / scratches. . The LPA interviewed eight residents. One resident was unable to respond due to cognitive impairment. The remaining seven residents denied the allegation and reported that staff are available and provide assistance according to residents’ needs. No concerns regarding supervision or staffing were reported. While LPA walked around to conduct resident interviews, LPA observed sufficient staff on duty and actively assisting residents. Review of the staff roster, daily staffing logs, caregiver schedules, and daily assignment sheets indicated that the facility maintained sufficient staffing to meet resident needs. Based on staff and resident interviews, observations, and record review, the allegation that staff failed to supervise R1 resulting in unexplained scratches was not corroborated. Regarding allegation: Staff did not administer medication as prescribed. It was alleged that staff was not applying ointments to R1 as prescribed. The Administrator and staff were interviewed and denied the allegation. They stated that all medications and ointments are administered and applied to residents in accordance with physicians’ orders and within required time frames. Staff reported that R1 had sensitive skin and that all prescribed creams and ointments were applied as ordered. Staff further stated that the facility purchased and provided sensitive-skin body wash to assist during periods when R1 experienced skin irritation flare-ups that caused itching. Continue 9099C The LPA reviewed R1’s file and medical records and observed documentation indicating that all prescribed creams and ointments were applied as ordered by the physician and within the prescribed time frames. The LPA interviewed eight residents. One resident was unable to respond due to cognitive impairment. The remaining seven residents denied the allegation and stated they had no concerns regarding the administration of their medications. Based on staff interviews, resident interviews, and record review, the allegation that staff failed to administer medication and apply prescribed ointments to R1 was not corroborated. Regarding allegations: Staff left the resident soiled and Staff allowed the resident to be malodorous. It was alleged that staff left the resident soiled and malodorous. The Administrator and staff were interviewed and denied the allegation. They stated that adequate staffing and supervision are maintained at all times and that residents are supervised according to their individual needs. Staff reported that R1 required full hands-on assistance with all activities of daily living, including meal setup with guidance and reminders, as well as incontinent care. Administrator and staff stated that R1 and other residents were never left soiled or malodorous. Staff reported that R1’s incontinence care was managed every shift and that R1 was checked at least every two hours, and more frequently as needed. Staff further stated that R1 was a wanderer and required frequent safety checks, encouragement to rest, and reminders to drink fluids. Staff indicated they did not observe R1 or other residents to be malodorous. The LPA interviewed eight residents, four of whom required incontinence care. Four residents stated that staff check on them frequently and change them as needed. Interviewed residents stated that they didn't noticed that residents are malodorous. One resident was unable to respond due to cognitive impairment. While LPA walked around to conduct resident interviews, LPA observed sufficient staff on duty assisting residents and did not observe any residents to be malodorous. Based on staff interviews, resident interviews, and LPA observations, the allegation that staff left R1 soiled and malodorous was not corroborated. Continue 9099C Regarding allegation: Facility did not provide a refund. It was alleged that the facility failed to issue a refund following R1’s move out. The final notice of intent to move R1 was received from R1’s responsible party. The Administrator and staff reported that the facility received an email from R1’s responsible party on 09/08/25 stating that R1 would be moving to another facility, with a discharge date of 09/10/25. The LPA reviewed email correspondence between R1’s responsible party and the facility administration, which confirmed that notification of the move was sent on 09/08/25 and that R1 was scheduled to move out on 09/10/25. Facility administration informed the responsible party that the email would be accepted as the required 30-day written notice, in accordance with the admission agreement. The LPA reviewed the Admission Agreement, specifically the Termination and Refund Policy, which states: “You may terminate this Agreement at any time, with or without cause, by giving the Administrator of the Community or his/her designee thirty (30) days prior written notice of termination. You need not cite a specific reason for termination.” Based on Admission Agreement R1's responsible party should pay the rent until 10/08/25 but since R1's belongings move on 09/10/25, facility Administration waived charges from 10/01/25 to 10/08/25 and refund was issued. The LPA requested and reviewed the monthly invoice for R1 and observed that R1 paid the full rent amount for September 2025 and on the invoice indicated that a refund for 20 days in the mount of September was issued to the responsible party. The LPA obtained a copies of invoice and the Check #6128 in the amount of $9,686.67. Check was cashed. Based on record review and documentation obtained, the facility issued a refund in accordance with the Admission Agreement. The allegation that the facility failed to provide a refund was not corroborated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted and a report was provided to Selene Rangel-Gutierezthe state’s words, verbatim · CDSS document, Jan 30, 2026 · control 28-AS-20250917141609

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with Director of Health Care Services Selene Rangel-Gutierrez who assisted with visit. PA explained the reason for the visit. The facility is licensed for 87 non-ambulatory residents aged 60 and older. Hospice Waiver approved for 25 residents. Currently 14 residents on hospice. Approved for delayed egress, secured perimeter, and secured locked perimeter. This is a 2 story building which includes Terrace Park (1st floor and 2nd floor) and Canyon View (1st floor). LPA toured the facility which included the following: common areas, kitchen, dining rooms, activity rooms, living rooms, medication rooms and laundry room. LPA observed disinfectant / cleaning solution in the cabinet located in the Terrace Park dining room. Required postings were observed. A random sample of resident rooms where toured in each building / floor. There are multiple shaded areas available for resident use. There is a pool on the premises that is surrounded by fencing and in compliance with state and local building codes. All indoor and outdoor passageways were free of obstruction. The water temperature was tested in a random selection of resident bathrooms in each floor and measured between 112.4F - 117.1F which is within the required 105F - 120F. Resident bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. Emergency call buttons were observed in every resident room. A random sample were tested and operable. Showers were free of mold and non-skid mats or strips were properly in place. Smoke detectors and carbon monoxide detectors were observed throughout the facility and in each resident room. Several fire extinguishers were observed throughout the facility in the hallways. Last Fire drills were conducted on 11/20/25. Continue 809C Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. 2 days perishable and 7 days non-perishable food observed. Laundry detergent were observed locked and inaccessible to residents in the laundry room. Multiple First Aid kits were inspected and were fully stocked with current manuals. Resident medications were randomly selected for review. Medications are centrally stored in the medication rooms. Medications are documented properly and given as prescribed. LPA reviewed clients and staff files and observed that all clients files are updated and confirmed that staff working have fingerprint clearances. Deficiency observed and documented on the attached 809D. Civil penalty issued. Exit interview held. A copy of the report and appeal rights were provided to Selene Rangel-Gutierez.the state’s words, verbatim · CDSS document, Jan 30, 2026

Allegation investigated: Staff do not meet incontinence care needs of residents. Staff do not dispense medications as prescribed.

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced complaint investigation to investigate the above allegations. LPA met with Selene Rangel, DHS (Director of Health Services) and explained the purpose of the visit. During this visit, LPA obtained a copy of the Resident and Staff rosters, obtained copies of relevant documentation, interviewed Staff 1 (S1) - Staff 7 (S7), Resident 1 (R1) - Resident 8 (R8). LPA also conducted a facility tour included med rooms. Continue 9099C Unsubstantiated Allegation: Staff do not meet incontinence care needs of residents. It was alleged that staff do not meet incontinent care needs of the residents (they are forced to sit in diapers full of feces for more than an hour) due to lack of caregivers. Interviewed staff denied the allegation. They stated that the facility has sufficient staff to meet all residents’ needs including incontinence residents. They stated that facility has enough staff to provide adequate care to residents in care. They assist residents with all their needs including diaper change. Facility has a 3-shift scheduled for morning, day, and night. They stated if there is a call off, they will replace the shift. It will be facility staff to work an extra shift, or facility will use staffing agencies to cover the shift. There are also student nurses on the floor almost every day. Interviewed staff stated that residents changed promptly, which is every 2 hours and as needed. If residents are soiled due to incontinence, they are changed right away. They are never forced to sit in diapers full of feces. LPA interviewed 8 residents of which 5 are incontinence. 4 residents stated the staff check their diapers often and change them as needed. 1 resident was unable to answer questions due to cognitive impairment. While LPA walked around to conduct resident interviews, LPA observed enough staff assisting residents. Also students from medical schools were present, assisting residents. Review of staff roster, daily staffing log, caregivers schedule and daily assignment sheet, indicates that the facility has sufficient staff to meet the needs of residents. Allegation: Staff do not dispense medications as prescribed. It was alleged that staff do not dispense medications as prescribed. A capsule was observed on the floor and the medication cup with a pill left in it. Interviewed staff denied the allegation. They stated that residents are receiving their medications as prescribed. Interviewed staff stated that medical staff dispense medication as prescribed. They stated that all nurses pass / administrate medications that are prescribed by doctor, there is no other way. Interviewed S1, S2 and S4 stated medications are popped up by LVN/ Med Tech before being administrated and given to residents by the staff who prepared the medication. If resident asks for medication to be left at his/her side that they can take independently, the staff / nurse will place the medication on the table in front of resident and remains at side of resident watching that resident swallow the medication. Staff does not walk away and leave the medication cup with a pill / medication in it. If they interrupted while popping medication, they will put the medication in the med. cart and lock it. Continue 9099C Interviewed S1 mentioned that approximately one year ago they found Tylenol on the floor in one of resident room, the family member that was present stated the medication was theirs and that they had dropped it when taking their daily medication. This is the only case that happened at the facility. Interviewed S2 - S7 stated that they didn't notice / found any medication / capsule on the floor / residents room. Residents interviewed were unable to corroborate the allegation. LPA reviewed medications for 6 residents. Those are being locked in the med. carts, administered as prescribed and indicated on the electronic Medication Administration Record (MAR). Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted and a report was provided to Selene Rangel- DHS.the state’s words, verbatim · CDSS document, Sep 30, 2025 · control 28-AS-20250924093048

Allegation investigated: Staff do not keep the facility clean and sanitary. Staff do not ensure that pets in the facility are managed and receive approrpriate care

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced 10 day complaint visit to investigate the allegations listed above. Upon arriving at the facility, LPA met with Administrator Vida Gwinn and Rangel-Gutierrez Selene DHS (Director of Health Care Services) who assisted with the visit. The reason for the visit was explained. The investigation consisted of the following: LPA Margaryan inspected the facility including dining areas and common areas, obtained a copy of the staff roster, residents roster, reviewed and obtain documentation relevant to this investigation and interviewed Administrator, DHS( Director of Health Services) , Staff 1 to Staff 3 (S1 to S3) and Resident 1 to Resident 7 ( R1 to R7). Continue 9099C Unsubstantiated In regards the allegation: Staff do not keep the facility clean and sanitary. It was alleged that there are approximately five (5) dogs freely roaming inside the facility and these animals have been observed defecating and urinating on the carpeted hallways, creating an ongoing foul odor. Interviewed staff denied the allegation. They stated that facility is always clean and sanitary. They stated that there are 4 community dogs and 2 residents dogs on the premises and all staff properly taking care of them. Interviewed Administrator and DHS (Director of Health Services) indicated that there is a Pet Policy in place and all staff follow the policy. Interviewed staff stated if accidents happened, dogs urinate and defecate on the carpet / floor, staff will directly pick up feces and call the maintenance department for disinfecting and cleaning. Plant operations also keep a carpet / floor cleaning schedule to rid of any incident that could have gone unwitnessed. Interviewed Administrator and DHS stated that they have not received any concerns/complaints from residents, visitors nor staff in regard facility having a foul odor. Seven (7) residents were interviewed. All 7 residents stated that they don't have any concerns/ complaints about the facility dogs and reported that facility clean there is a no foul odor at the facility. LPA also conducted a tour of the facility and not observed any feces on the carpeted hallways. In regards the allegation: Staff do not ensure that pets in the facility are managed and receive appropriate care. It was alleged that the facility dogs often seen inside patient rooms and common areas and residents have been seen stepping in the facility dogs feces and dogs being fed by residents during lunch time, using their hands and utensils. Interviewed staff denied the allegation. They stated that there are 4 community dogs and 2 residents dogs on the premises and facility staff ensure that dogs are managed and receive appropriate care. Interviewed Administrator and DHS (Director of Health Services) stated have not received any concerns/complaints from residents, visitors nor staff in regard residents stepping in the facility dogs feces and / or dogs being fed by residents during lunch time, using their hands and utensils. They indicated that dogs are not allowed in residents room and not allowed in the dining areas during mealtimes. Interviewed staff stated that they didn't witness that resident stepped facility dogs feces. They stated that if accidents happened, dogs urinate and defecate on the carpet / floor, staff will directly pick up feces and call the maintenance department for disinfecting and cleaning. Interviewed staff indicated that dogs not allowed in residents room and dining areas during the mealtimes. Continue 9099C Seven (7) residents were interviewed. All 7 residents stated that they don't have any concerns/ complaints about the facility dogs and reported that never stepped dogs feces. They stated they didn't fed dogs in the dining areas using their hands and utensils. LPA conducted tour at the facility including dining room and didn't see dogs in the dining areas. Interviewed staff and residents stated that residents enjoy the dogs and dogs make residents happy. LPA obtained and reviewed the Pet Philosophy and Policies & Procedures, Resident and Family Handbook which indicated that pets are welcome to facility. Handbook provided to all residents and family members with Residency Agreement. Based on the observation, interviews conducted with the residents and staff although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED An exit interview was conducted, and a copy of this report was provided to Director of Health Care Services.the state’s words, verbatim · CDSS document, Jun 20, 2025 · control 28-AS-20250613122057

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with Director of Health Care Services Selene Rangel-Gutierrez who assisted with visit. PA explained the reason for the visit. The facility is licensed for 87 non-ambulatory residents aged 60 and older. Hospice Waiver approved for 25 residents. Currently 6 residents on hospice. Approved for delayed egress, secured perimeter, and secured locked perimeter. This is a 2 story building which includes Terrace Park (1st floor and 2nd floor) and Canyon View (1st floor). LPA toured the facility which included the following: common areas, kitchen, dining rooms, activity rooms, living rooms, medication rooms and laundry room. LPA observed cleaning solution, nail polish jar, nail clipper and the duracell batteries in the drawer of the cabinet located in the Terrace Park dining room. Required postings were observed. A random sample of resident rooms where toured in each building / floor. There are multiple shaded areas available for resident use. There is a pool on the premises that is surrounded by fencing and in compliance with state and local building codes. All indoor and outdoor passageways were free of obstruction. The water temperature was tested in a random selection of resident bathrooms in each floor and measured between 110.2F - 116.2F which is within the required 105F - 120F. Resident bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. Emergency call buttons were observed in every resident room. A random sample were tested and operable. Showers were free of mold and non-skid mats or strips were properly in place. Smoke detectors and carbon monoxide detectors were observed throughout the facility and in each resident room. Several fire extinguishers were observed throughout the facility in the hallways. Last Fire drills were conducted on 02/04/25. Continue 809C Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. LPA observed that there is a sufficient perishable food for 2 days but not enough non-perishable food was observed for 7 days. Cleaning supplies and toxins were observed locked and inaccessible to residents in the laundry room. Multiple First Aid kits were inspected and were fully stocked with current manuals. Resident medications were randomly selected for review. Medications are centrally stored in the medication rooms. Medications are documented properly and given as prescribed. LPA reviewed 6 resident records and 4 staff records. Per California Code of Regulations, Title 22, the deficiencies observed are documented on the attached 809D. Exit interview held. A copy of the report and appeal rights were provided to Selene Rangel-Gutierez.the state’s words, verbatim · CDSS document, Feb 24, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with Director of Health Care Services Selene Rangel-Gutierrez who assisted with visit. PA explained the reason for the visit. The facility is licensed for 87 non-ambulatory residents aged 60 and older. Hospice Waiver approved for 25 residents. Currently 6 residents on hospice. This is a 2-story building which includes Terrace Park (1st floor and 2nd floor) and Canyon View (1st floor). LPA toured the facility which included the following: common areas, kitchen, dining rooms, activity rooms, living rooms, medication rooms and laundry room. Required postings were observed. A random sample of resident rooms where toured in each building / floor. There are multiple shaded areas available for resident use. There is a pool on the premises that is surrounded by fencing and in compliance with state and local building codes. During the tour LPA observed wood pallets, old / broken commodes, old / broken commercial sink, broken grill, broken old furniture in the back of facility, and in the front of laundry room. The water temperature was tested in a random selection of resident bathrooms in each floor. Water temperature was tested in the bathrooms in the rooms # 17, # 15, and # 14 and the reading shows 120.3 degree F, 122.5 degree F and 66.7 degree F. Resident bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. Emergency call buttons were observed in every resident room. A random sample were tested and operable. Showers were free of mold and non-skid mats or strips were properly in place. Smoke detectors and carbon monoxide detectors were observed throughout the facility and in each resident room. Several fire extinguishers were observed throughout the facility in the hallways. Last Fire drills were conducted on 02/12/24 and 02/15/24. Continue 809C Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed. Cleaning supplies and toxins were observed unlocked and accessible to residents in the laundry room. Multiple First Aid kits were inspected and were fully stocked with current manuals. 6 resident medications were randomly selected for review. Medications are centrally stored in the medication rooms. Medications are documented properly and given as prescribed. LPA reviewed 3 resident records and 4 staff records. Per California Code of Regulations, Title 22, the deficiencies observed are documented on the attached 809D. Exit interview held. A copy of the report and appeal rights were provided to Selene Rangel-Gutierez.the state’s words, verbatim · CDSS document, Mar 12, 2024

Allegation investigated: Facility staff did not report changes in a resident's medical condition to their physician, resulting in hospitalization. Facility did not follow correct reporting requirements.

Licensing Program Analyst (LPA) Angelica Rea conducted an initial complaint visit in response to the allegations listed above. LPA met with RN/Director of Health Services, Selene Rangel, who assisted with today's visit. Regarding the allegation that : Facility staff did not report changes in resident #1's medical condition to their physician, resulting in hospitalization. The investigation consisted of review of resident #1's file, and interview(s) with staff #1, and staff #2. The investigation revealed the following: resident #1 has lived at the facility since 9/29/23. Review of resident #1's file indicates that resident #1 is regularly seen by their physician. LPA observed detailed progress notes for resident #1 for the period of 12/31/23 - 1/20/24. Staff interviewed stated that resident #1 was observed by staff on1/2/24, and noted to have cough and congestion. Staff reported this to resident #1's physician, and resident #1 was seen by their physician on 1/2/24. Resident #1's physician ordered a chest x-ray. Chest x-ray results were obtained on 1/4/24. On 1/18/24, staff reported to resident #1's physician, that resident #1 was observed to have a change in condition. Unsubstantiated Resident #1 was seen by physician on 1/18/24, and labs were ordered. Facility RN received lab results for resident #1 on 1/20/24, noted abnormal lab results and notified resident #1's physician. Physician ordered resident #1 to be transferred to hospital on 1/20/24. LPA was provided with documentation of chest x-ray, and lab results. Staff interviewed stated that resident #1's responsible party was notified, and provided documentation. Resident #1 was discharged to a skilled nursing facility, following hospitalization and has not returned to the facility. LPA observed that staff are reporting changes in resident #1's medical condition to resident #1's physician. Regarding the allegation that : Facility did not follow correct reporting requirements. The investigation consisted of review of resident #1's file, and interviews with staff #1 and staff #2. Staff interviewed stated that resident #1's responsible party /Power of Attorney (POA) is always notified regarding changes in resident #1's condition. Facility provided documentation that resident #'1's responsible party was notified regarding recent hospitalization. LPA observed that the facility submitted a special incident report to Community care licensing, as required. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 28-AS-20240124130220

Allegation investigated: Staff are not ensuring residents are receiving their phone calls. Facility is not ensuring adequate staffing.

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced 10 day complaint visit to investigate the allegations listed above. Upon arriving at the facility, LPA met Rangel-Gutierrez Selene DHS who assisted with the visit. The reason for the visit was explained. The investigation consisted of the following: LPA Margaryan toured the facility, obtained a copies of the staff roster, residents roster. LPA Margaryan also obtained copies of documents pertaining to Resident#1 (R1) including notes from staff in regards to R1's phone calls. LPA interviewed Staff#1 - Staff #5 (S #1 - S #5) and Resident #1 - Resident #6 (R #1 - R #6). Cont. 9099C Unsubstantiated Allegation: Staff are not ensuring residents are receiving their phone calls. It was alleged that unknown staff told caller that R #1 either busy, napping or only has one caregiver and is unable to go get him the phone. Staff interviews were conducted. Per staff interviews, staff are ensuring that residents are receiving phone calls. Per staff interviews, most residents residing at this facility do not use the telephone often due to their dementia and/or family involvement. Interviewed staff reported its residents personal right to use the facility phones any time, receiving or making calls. Staff stated when residents are receiving a phone calls, staff is locating the residents and they can speak on the phone to the caller. In case of residents are taking naps, resting or at the time of meals, they will ask caller, call residents back and taking massages, asking call back number. But most of the time residents are taking calls after staff transferring calls to them. Interviewed staff stated that facility has a total 13 phones available for residents to use: 7 land lines and 6 cell phones. During the facility tour LPA observed Telephones / land lines are located in Reception area, Wellness CT-CV, Wellness CT-TP, Middle Canyon View, Upstairs TP Tuscany, TP Dinning Room, Back- Social Worker Office and Cell phones in Reception area, CV Nurse office (2) , TP nurse office (2) and Unit Secretary phone. Interviewed staff stated when R1 received phone calls from the family members staff always transfer calls to R1. When R1 is napping , participating in activities or eating meals staff will ask callers call back. LPA obtained and reviewed staff notes regarding R1 calls received past few days: 10/19/23, 10/22/23, 10/23/23. Staff stated sometimes callers waiting on the line a few minutes until staff locating the residents, and they don't like it. During today’s visit, LPA interviewed R#1 - R #6. Resident interviews revealed that residents are receiving phone calls. Interviews conducted do not corroborate this allegation. Cont. 9099C Allegation: Facility is not ensuring adequate staffing. It was alleged that there is one caregiver and is unable to get Resident #1 the phone. Interviewed staff denied the allegation. They stated that Facility has enough staff. Staff stated that there is a paging system / walkie - talkie to page the staff to locate the residents. S3 or other staff never told the caller there is a only one caregiver and is unable to get R #1. When R1 or other residents are receiving calls from the family members, staff always transfer calls to R1 or other residents. Staff stated that not only caregivers are locating residents to get a calls. All staff at the facility have walkie- talkies and can hear the page. Staff who is available/has a cell phones will assist residents with the calls. Based on documents reviews, observation and interviews, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED An exit interview was conducted, and a copy of this report was provided to Rangel-Gutierrez Selene Director of Health Care Services.the state’s words, verbatim · CDSS document, Oct 24, 2023 · control 28-AS-20231019092218

Allegation investigated: Staff did not adequately supervise resident resulting in resident falling. Resident is dehydrated.

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced 10 day complaint visit to investigate the allegations listed above. Upon arriving at the facility, LPA met Rangel-Gutierrez Selene DHS who assisted with the visit. Shortly after Administrator Almavida Gwinn arrived. The reason for the visit was explained. The investigation consisted of the following: LPA Margaryan toured the facility, obtained a copies of the staff roster, residents roster LPA Margaryan also obtained copies of documents pertaining to Resident#1 (R1) including: Residency Agreement, Admission Record, Identification and Emergency Information, Preplacement Appraisal Information, Resident Appraisal, Physician's Report, Physician Order Review, Neurological Observation Results, Vital Signs Trend, Unusual Incident/Injury Report (SIR) dated 10/05/23. Interviews were conducted with 5 staff (S1 - S5) , 6 residents (R1 - R6) and 1 Family member (F1) Cont. 9099C Unsubstantiated The investigation revealed the following: Allegation: Staff did not adequately supervise resident resulting in resident falling. During this investigation, LPA obtained relevant documentation and interviewed staff and residents. Interviewed staff members denied the allegation. Interviewed staff indicated , there is always enough staff at the facility and they provide supervision to all residents in care. R1 does not have a one-on-one caregiver. Based on interviews conducted the findings indicate that resident (R1) sustained a fall on October 05, 2023. The resident was noted by S5 sitting on the floor in the living room. Per S5 a few minutes prior R1 was engaging in activity. S5 immediately notified the LVN. A body check was perform and noted abrasion to the back of the R1's head. Staff help R1 to stand and sit on the coach. LVN clean the abrasion with the saline water and put antibiotic ointment. R1 didn't show any sign of discomfort or pain. R1 was able to walk and ask for the tea and Icecream. Primary doctor and responsible party were notified. Neurological checks conducted. After incident, staff closely monitor the R1 for 2 days and R1 didn't complain of any pains. Residents interviewed were unable to corroborate the allegation. Interviewed residents indicated staff conduct rounds often throughout the entire day. 5 out of 6 residents stated that staff provide adequate supervision. LPA interviewed R1 who just answer "Yes" to all questions .R1 was unable to provide details and/or dates of alleged falls. Interviewed F1 who was visiting R5's at the time of visit stated that there is always enough staff to supervise the residents. At the time of visit LPA observed sufficient staff at the facility. LPA also observed that students from the Nursing School are assisting the residents. Facility staff schedule was reviewed, and it confirm that facility has a sufficient staffing at all the time. There is insufficient evidence to prove the alleged allegation. Documentation reviewed and interviews conducted with staff and residents do not corroborate this allegation. Cont. 9099C Allegation: Resident is dehydrated. It was alleged that R1 is very dehydrated. Staff interviewed denied the allegation and stated they have not received any complaints nor concerns in regards the allegation. Staff also stated that sometimes residents refused to eat lunch or dinner, but was reminded to drink fluids. Juice and water are provided during all day. Residents often received water supplies from family as well. R1 is one of them. The facility has six (6) water stations that all residents can access throughout the day. Residents can request fluids at any time of the day, and staff take the fluids to the resident room when requested. Residents interviewed did not corroborate the allegation. Residents indicated staff ensure residents have adequate drinking water. All Interviewed residents stated the facility provided drinks/fluids. They stated never dehydrated. During the visit, LPA observed residents getting water from water stations with plenty of water. LPA observed staff encouraging residents to drink the water. Based on file reviews, observation and interviews, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED An exit interview was conducted, and a copy of this report was provided to Rangel-Gutierrez Selene Director of Health Care Services.the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 28-AS-20231013083953