Skyline Place Senior Living

Allegation investigated: Illegal eviction Facility failed to report neglect by POA

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to this facility to deliver complaint findings. LPA Lund met with Executive Director Valerie Pais and explained the purpose of the visit. Illegal eviction- LPA Lund reviewed facility paperwork and interviewed staff. Based on reviewed facility paperwork and interview with staff. LPA Lund reviewed the Unlawful Detainer that Resident (R1) was given. The facility did the proper Unlawful Detainer and the Tuolumne County Sheriff’s Department removed R1 on 4/4/2026. R1’s Power of Attorney was not able to make it and the Tuolumne County Sheriff’s Department took R1 to the Emergency room until R1 was moved to a long-term facility. Unsubstantiated Based on reviewed facility paperwork and interview with staff, on the information provided, it was unclear if of an illegal eviction, therefore the allegation was deemed UNSUBSTANTIATED. Facility failed to report neglect by POA- LPA Lund reviewed facility paperwork and interviewed staff. Based on reviewed facility paperwork and interview with staff. LPA Lund reviewed facility communication with Resident (R1) Power of Attorney (POA). The POA was not able to make it the payments do to R1’s change in finances. The POA tried to make payments and was not able to do so and that was the reason for the Unlawful Detainer. Based on reviewed facility paperwork and interview with staff., on the information provided, it was unclear if facility failed to report neglect by POA, therefore the allegation was deemed UNSUBSTANTIATED. As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and report left.the state’s words, verbatim · CDSS document, Jul 29, 2026 · control 27-AS-20260401103909

Allegation investigated: Staff are threatening resident with eviction Staff are not providing reasonable accommodations for resident

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to this facility to deliver complaint findings. LPA Lund met with Executive Director Valerie Pais and explained the purpose of the visit. Staff are threatening resident with eviction- LPA Lund reviewed facility paperwork and interviewed staff. Based on reviewed facility paperwork and interview with staff. Resident (R1) never received a notice of eviction from the facility. R1 gave a 30- day notice on 4/9/2026 and moved to another facility. Unsubstantiated Based on reviewed paperwork and interview with staff, on the information provided, it was unclear if staff are threatening resident with eviction, therefore the allegation was deemed UNSUBSTANTIATED. Staff are not providing reasonable accommodations for resident- LPA Lund reviewed facility paperwork and interviewed staff. Based on reviewed facility and interview with staff LPA Lund reviewed the pet policy from the facility which Resident (R1) signed on 7/11/2025. The pet policy states that it is the discretion on the Executive Director’s for resident’s to have pets or not. R1 had a pet who passed away and per discretion of Executive Director was not allowed to have another pet. Based on reviewed facility and interview with staff, on the information provided, it was unclear if staff are not providing reasonable accommodations for resident, therefore the allegation was deemed UNSUBSTANTIATED. As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and report left.the state’s words, verbatim · CDSS document, Jul 29, 2026 · control 27-AS-20260402094936

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jason Lund arrived unannounced. To deliver ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES. LPA Lund verified that Staff (S1) never worked at the facility and was take on Guardian as of 7/28/2026 Facility understands this is an Immediate Exclusion effective today. S1 is excluded and prohibited from being a licensee, owning a beneficial ownership of 10% interest or more in a licensed facility, or being an Administrator, officer, director, member, or manager of a licensee or entity controlling a licensee. S1 cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Per California Code of Regulations, Title 22 Division 6, Chapter 8, No deficiencies were observed and cited. Exit interview held, Copy of report giventhe state’s words, verbatim · CDSS document, Jul 29, 2026

Allegation investigated: Staff did not prevent inappropriate interactions between residents in care Resident lost drastic weight while in care due to staff neglect Staff did not ensure that the resident’s bathing care needs were properly met

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to this facility to deliver complaint findings. LPA Lund met with Executive Director Valerie Pais and explained the purpose of the visit. Census 107 Allegation-Staff did not prevent inappropriate interactions between residents in care- It was alleged that staff did not prevent inappropriate interactions between residents in care. During the course of this investigation, the department conducted interviews and reviewed facility records. Based on interviews conducted it was denied by facility staff that they did not prevent an inappropriate interaction between the residents in care. Facility staff state that the residents are in a consensual relationship and report that both residents are able to express this. In addition, facility staff report that the resident’s family members are aware of the interactions with these residents and report no issues. An interview with the residents were conducted who corroborate these statements. Based on the information gathered, there is not sufficient evidence to prove that the staff did not prevent inappropriate interactions between residents in care. Unsubstantiated Allegation- resident lost drastic weight while in care due to staff neglect-It was alleged that a resident lost drastic weight while in care due to staff neglect. During the course of this investigation, the department conducted interviews and reviewed facility records. Based on interviews conducted it was denied by facility staff that the resident lost drastic weight while in care. It was reported that the resident had maintained weight while on hospice. Further interviews Based on the facilities records, LPA Pascua reviewed the residents weight record in which showed that the resident has not had a drastic weight loss while in care. Based on the information gathered, there is not sufficient evidence to prove that the resident lost drastic weight while in care due to staff neglect. Allegation- Staff did not ensure that the resident’s bathing care needs were properly met-It was alleged that facility staff did not ensure that the resident’s bathing care needs were properly met. During the course of this investigation, the department conducted interviews and reviewed facility records. Based on interviews conducted, it was denied by facility staff the they did not ensure that the resident’s bathing needs were not met. Facility staff report there have been no issues with ensuring that the resident’s needs are met. In addition, an interview with the resident’s family report that they have no issues with the care needs of the resident. Based on the information gathered, there is not sufficient evidence to prove that the staff did not ensure that the resident’s bathing care needs were properly met. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Feb 9, 2026 · control 27-AS-20251203101619

Allegation investigated: Lack of supervision resulted in a resident harming another resident Unauthorized charge to resident's account

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to this facility to deliver complaint findings. LPA Lund met with Executive Director Valerie Pais and explained the purpose of the visit. Census 107 Allegation: Lack of supervision resulted in a resident harming another resident. It was alleged that due to lack of supervision it resulted in a resident harming another resident. During the course of this investigation, LPA conducted interviews and reviewed facility records. Based on interviews conducted, it was determined that on 12/11/2025, R1 and R2 were in an elevator traveling to dinner. R2 was using an assistive device while exiting the elevator, at which time R1 became impatient and pulled R2’s hair and struck R2 with a cane. Substantiated A review of R1’s pre-admission appraisal indicates that R1 has a tendency to become easily frustrated and may lash out physically. Additionally, R1’s care plan documents occasional behavioral issues, including aggressive behavior, socially inappropriate conduct, and verbally or physically inappropriate actions. The care plan further specifies that facility staff are required to demonstrate special tolerance and/or receive appropriate training. It also states that R1 is to be monitored for safety and redirected to a calmer, quieter environment at the early signs of behavioral escalation. Based on this information, due to lack of supervision it resulted in a resident harming another resident. As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes Allegation: Unauthorized charge to resident's account-It was alleged that there were unauthorized charges to the resident’s account. During the course of this investigation, LPA conducted interviews and reviewed facility records. Based on interviews conducted, it was learned that the facility admitted that their records show that the facility added an addition charge for care to the resident’s ledger without notifying the resident. In addition, a review of the facilities files show that the facility administrator asked for the resident’s account to be credited the amount that was initially taken off accidentally. Based on the information gathered, there is sufficient evidence to prove that there were unauthorized charges to the resident’s account. As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. An exit interview was conducted and a copy of this report and appeals rights was provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Feb 9, 2026 · control 27-AS-20251212161459

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(e) · Plan of correction due date: Feb 10, 2026

(e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This is not met as evidenced by: Based on interview and record review, the licensee did not ensure that the facility had proper supervision to monitored R1 from physically assaulting R2. This poses an immediate health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Feb 9, 2026

Plan of correction: Licensee shall provide a statement of correction to the LPA by POC date. Facility shall have an update care plan that specifies how they will assist and mitigate R1’s behavior from harming other residents in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(3)(B)2 · Plan of correction due date: Feb 23, 2026

2. A separate charge for an item or service may be assessed only if that charge is included in and authorized by the admission agreement.This is not met as evidenced by: Based on interview and record review, the licensee did not ensure that the resident’s responsible party was notified of the additional charges on the resident’s care plan. This poses a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Feb 9, 2026

Plan of correction: Licensee shall provide statement of acknowledgement and correction to LPA by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst Jason Lund arrived at the facility unannounced to complete an one year required inspection. LPA Lund met with Executive Director Valerie Pais and explained the purpose of the visit. Census: 107 The facility is a Residential Care Facility for the Elderly and is licensed for clients age 60 and over. The facility has a capacity of 135 non-ambulatory residents. There may be 35 bedridden residents and there is a hospice waiver granted for 17. LPA Lund and Executive Director Valerie Pais toured/inspected the facility including the five floors that have Memory Care and Assisted Living in separate units. LPA Lund observed memory care rooms that were furnished appropriately. Bathrooms were in the hall and hot water was measured at 115.9 degrees Fahrenheit (F). Residents in Assisted living had their own bathrooms and hot water was measured at 115.1 degrees which is within the requirement of 105- and 120-degrees F. The resident rooms were equipped with all required furniture. The assisted living section of the facility has call signals in the living area, bedroom and bathroom of each unit. The facility was observed to be sanitary, and all furniture was in good repair. The kitchen maintains documentation on residents that require special diets that is readily accessible by the kitchen staff. There was 2- days of perishable food and 7- days of non-perishable food. LPA Lund reviewed the fire drill log for January. Fire drill procedures and the sign-in sheet for all participants were included. Fire extinguishers were last inspected on 02/04/2025. The Ansul system was last serviced in March of 2024 and is in compliance. Thermostats were set at 72 degrees F. LPA Lund reviewed 9 residents files and 7 staff files that were complete and in compliance. Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 9, 2026

Allegation investigated: Staff does not provide adequate resident care.

On 10/1/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to deliver complaint findings. LPA Lindstrom met with Administrator Valarie Pais, explained the purpose of the visit, and conducted an interview. Allegation: Staff does not provide adequate resident care. On 6/5/2025, LPA Arielle Pascua conducted the 10-day site visit and interviewed two staff. S1 stated that a resident’s family had recently been concerned about them, but S1 had explained to the family that the resident’s health was declining and that they were developing new behavioral expressions. S1 stated that no other issues had been brought to their attention. S2 stated that there were no complaints with any families regarding care at this time. On 9/8/2025 and 9/10/2025, LPA Lindstrom interviewed three family members and three staff members. Unsubstantiated F1 stated that staff were meeting their family member’s care needs and that they had no concerns about health and safety. F2 stated that staff was very responsive and checked on their family member frequently. F3 stated that staff was on top of resident care and was always responsive when they brought issues to staff’s attention. S3 stated that they had not seen any issues with resident care, that staff provided adequate incontinence care, and that staff backed each other up when answering call buttons. S4 stated that when they are short staffed, call button response time may be slower than usual or showers may be delayed, but S4 can still meet all residents’ incontinence needs. S5 stated that incontinence care was sometimes inadequate. On 9/15/2025, LPA Lindstrom interviewed two residents. R1 stated that all her care needs were met. R2 repeatedly stated that staff does a good job meeting their needs. Based on interviews and record review, the allegations that staff does not provide adequate resident care is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. As a result of this investigation, no deficiencies were cited. The facility was in compliance with California Code of Regulations (CCR), Title 22, Division 6. An exit interview was conducted with the Administrator and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 27-AS-20250530110109

Type of visit: Case Management - Infectious Disease Outbreak

On 10/1/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a case management site visit regarding a recent COVID outbreak at the facility. LPA Lindstrom met with the Administrator, explained the purpose of the visit, and conducted an interview. LPA Lindstrom observed a notice on the front door of the facility with information about the COVID outbreak and that staff were wearing N-95 masks. The administrator stated that a total of seventeen staff and residents have tested postive for COVID since 9/19/2025. The Administrator notified the Public Health Department on 9/22/2025 and has been notifying Public Health and the Department weekly since. The facility has been following its infection control plan and has notified families of residents. An exit interview was conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 1, 2025

Allegation investigated: Staff leave residents in soiled diapers/linens for extended period of time.

On 9/14/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom and Licensing Program Manager (LPM) Lisa Rios arrived at the facility unannounced to follow-up on this complaint/deliver complaint findings. LPA Lindstrom met with Administrator Valarie Pais (S1) and explained the purpose of the visit. The LPA interviewed three family members (F2, F4, and F5), who reported that they had had no issues with incontinence care at the facility. On 9/8/2025, LPA interviewed two staff (S6 and S8), who reported having observed residents receiving inadequate incontinence care. S6 stated that they had seen some residents in soaked briefs every day or every other day. S8 stated that they had observed bedbound residents left in soiled briefs and some residents with skin breakdown. (Continued on 9099-D) Unsubstantiated On 9/15/2025, LPA Lindstrom interviewed two residents (S4 and S5). S4 stated that they had experienced no issues with incontinence care. S5 stated that staff did a good job with incontinence care and that their room remained odor-free. The LPA Lindstrom observed S5's room and it was odor-free. Based on interviews and record review, the above allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. As a result of this investigation, no deficiencies were cited. The facility was in compliance with California Code of Regulations (CCR), Title 22, Division 6. An exit interview was conducted and copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 15, 2025 · control 27-AS-20250820090538

Allegation investigated: Staff did not administer residents' medications as prescribe. Staff providing care and supervision while impaired.

On 9/14/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom and Licensing Program Manager (LPM) Lisa Rios arrived at the facility unannounced to follow-up on this complaint/deliver complaint findings. LPA Lindstrom met with Administrator Valarie Pais (S1) and explained the purpose of the visit. Allegation: Staff did not administer residents' medication as prescribed On 9/10/2025, Licensing Program Analyst (LPA) Lindstrom reviewed the facility’s electronic medication administration record (EMAR) for all facility residents for the month of May 2025. The EMAR showed no pattern of missed medication administration in the resident population for both the morning and afternoon passes on any one day in May. LPA Lindstrom interviewed three family members (F2, F4, and F5) and three staff (S4, S6, and S8), all of whom stated that they had not observed any issues with medication administration. Unsubstantiated Allegation: Staff providing care and supervision while impaired. On 9/8/2025, LPA Lindstrom interviewed two staff (S4, and S6), who stated that they had never observed care staff impaired on the job. S4 stated that they would not tolerate this. S6 stated that they would have reported it if they had seen this. LPA Lindstrom interviewed one staff (S8), who stated that another care staff (S9) told S8 that they were high on-the-job, and that this was reported to management. On 9/15/2025, LPA Lindstrom interviewed two residents (R4 and R5), who stated that they had never seen care staff impaired on the job. Based on interviews and record review, the allegations that staff did not administer residents' medication as prescribed and staff providing care and supervision while impaired are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. As a result of this investigation, no deficiencies were cited. The facility was in compliance with California Code of Regulations (CCR), Title 22, Division 6.the state’s words, verbatim · CDSS document, Sep 15, 2025 · control 27-AS-20250820170659

Allegation investigated: Staff did not report incident to appropriate parties in a timely manner

On 9/15/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to follow-up on this complaint and deliver complaint findings. LPA Lindstrom met with Administrator Valarie Pais (S1) and explained the purpose of the visit. On 8/27/2025, LPA Lindstrom interviewed S1, who stated that a med tech noticed that a resident was missing from the facility about 10:30 AM on 8/23/2025. LPA Lindstrom received a phone call and voice mail from S1 at 11:41 AM on 8/23/2025 stating that a resident was missing from the facility, and a second call from S1 at 3:20 PM on 8/23/2025 stating that the resident was still missing, that the elopement had been reported to law enforcement, and that Search and Rescue were helping with the search. On 8/26/2025, S1 submitted an LIC624 Unusual Incident/Injury Report to the Department about R1’s rescue. On 8/29/2025, S1 submitted an additional LIC624 to the Department that documented R1’s elopement and the subsequent facility response in detail. Unsubstantiated On the 8/29/2025 LIC624, S1 indicated the following reporting sequence: S2 was notified by facility staff that R1 was missing at approximately 10:50 AM. S2 notified S1 of the elopement at approximately 11 AM. S1 notified R1’s Power of Attorney (POA) at approximately 11 AM. LPA Lindstrom interviewed a family member (F1) of R1, who verified that S1 notified F1 of the elopement around 11 AM on 8/23/2025. The facility immediately initiated its elopement protocols, and staff searched the facility and grounds for R1. S1 called 911 at approximately 11:55 AM to report R1 missing. Based on interviews with staff and family and records reviewed, the allegation that staff did not report incident to appropriate parties in a timely manner is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. As a result of this investigation, no deficiencies were cited. The facility was in compliance with the California Code of Regulations (CCR), Title 22, Division 6. An exit interview was conducted with the Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 15, 2025 · control 27-AS-20250825115709

Type of visit: Case Management - Deficiencies

On 9/15/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom and LPM Lisa Rios arrived at the facility unannounced to Skyline Place Senior Living. During the visit, it was determined that an incident took place in May of 2025 where a staff self reported to being high prior to starting to work that day. The facility terminated and separated S1 on 5/13/25. The incident was never reported to the Department which poses a potential risk to residents in care. A Type B citation is being issued today. See LIC809D attached. Exit interview was conducted and a copy of appeal rights was given to Administrator Valerie Pais.the state’s words, verbatim · CDSS document, Sep 15, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Sep 29, 2025

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence .... (D) Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by: interview with Admin stated that S1 was termintaed for attempting to come to work high. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: Admin will submit an LIC624 for the incident. Admin will also go over the regulation with the staff and reporting requirements and how they can effect residents in care and residents at another facility. Admin will hold an inservice with staff and submit a signed roster of all present to LPA Lindstrom.

Allegation investigated: Lack of supervision, resulting in resident eloping from facility

On 8/27/2025, Licensing Program Analysts (LPAs) Vincent Moleski and Triel Ellen Lindstrom arrived unannounced to open this complaint investigation. LPAs Moleski and Lindstrom met with Administrator Valarie Pais and explained the purpose of the visit. The LPAs interviewed Pais and reviewed two LIC 624s submitted by the facility about a resident elopement that occurred on Saturday 8/23/2025. Pais stated that on the morning of 8/23/2025, a med tech went to the resident’s room about 8:30 AM to pass medications. The resident’s spouse stated that she was sleeping. When the med tech returned about 9:30 AM to pass medications, the resident’s spouse stated that the resident was out walking their dog. When the med tech returned about 10:30 AM to pass medications, the resident’s spouse stated that the resident had not returned to their room. The med tech called the Administrator to report the resident’s absence and the facility began their elopement protocol. [continued on 9099-C] Substantiated The Administrator called the resident's child, their attorney in fact, about 11 AM to inquire whether the resident was at their home. The Administrator called the Tuolumne County Sheriff’s Office a little before noon to report the elopement. Staff began a search of the facility for the resident, including resident rooms, facility grounds, and perimeter of the facility. The Administrator and facility staff joined the SARs teams with the search of the surrounding area, including the neighborhood adjacent to the facility up the hill, as the resident’s friend and child currently live there. The Administrator reviewed video footage from a nearby business and church. The resident was found by a SAR team on Sunday evening 8/24/2025 located in bushes down a ravine. The Administrator rode with the resident in the ambulance to the hospital. The Administrator stated that the resident had no injuries, but was dehydrated. The resident was released from the local hospital on Monday 8/25/2025 about 3:30 AM and returned to the facility. The resident and their spouse moved into a new unit in Memory Care that same day. The LPAs reviewed the resident’s service plan dated 11/22/2024. The LPAs observed that the plan included the goal that the resident had a “History of wandering outside the community…Health and safety may be jeopardized.” The resident was reappraised after the 8/23/2025 elopement to ensure that their current service plan addressed the resident’s recent wandering. The resident’s new plan dated 8/26/2025 includes the same goal with the same language as the 11/22/2024 plan in regard to wandering. The LPAs reviewed the resident’s LIC 602A Physician’s Report for Residential Care Facilities for the Elderly (RCFE), signed by a physician on 1/6/2025. The report stated on page 4 that the resident was “Able to leave the facility unassisted.” This report does not reflect the information contained in the service plan written a month and a half before. The 1/6/2025 LIC 602A was based on the resident’s last exam, which was in late September 2024, prior to the completion of the resident’s service plan in November 2024. The resident was diagnosed with dementia and epilepsy, according to the LIC 602. No documentation was available to suggest that the resident’s physician was notified of the wandering behavior identified in their November 2024 service plan. This deficiency will be addressed in a separate report. The LPAs noted that the resident’s file did not contain an elopement risk assessment prior to the resident’s recent elopement on 8/23/2025. Health and Safety Code Section 1569.312(d) states that facility staff must remain “aware of the resident's general whereabouts, although the resident may travel independently in the community.” Additionally, 22 CCR Section 87705(e)(5) states that “Facility staff shall ensure the continued safety of residents [with a dementia diagnosis] if they wander away from the facility…” This facility is hereby cited per 22 CCR Section 87705(e)(5). Due to a violation involving a lack of supervision of a resident, a civil penalty in the amount of $500 is hereby assessed. The licensee was informed that a civil penalty assessment based on Health and Safety Code Section 1569.49(f) is currently under review and may be assessed at a later date. Once this has been determined, CCLD personnel will return to assess the civil penalty, if necessary. An exit interview was held. Appeal rights and a copy of this report were left with Pais.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 27-AS-20250825115709

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(e)(5) · Plan of correction due date: Aug 28, 2025

“Facility staff shall ensure the continued safety of residents if they wander away from the facility without violating Sections 87468.1, Personal Rights of Residents in All Facilities and Section 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities.” This requirement was not met as evidenced by: Based on interview and record review, facility staff were aware of previous wandering behaviors which jeopardized the health and safety of the resident, yet did not ensure the resident’s safety during an episode of wandering behavior, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Licensee agrees to provide staff trainings on the topics of elopement and notification procedures. Licensee agrees to provide LPA Lindstrom a plan regarding these scheduled trainings by POC due date.

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Triel Lindstrom and Vincent Moleski arrived unannounced to conduct a complaint investigation. However, during that investigation, LPAs Lindstrom and Moleski observed an unrelated deficiency. A resident of this facility (R1) left to walk their dog on or around the morning of Saturday, August 23, 2025, according to facility administrator Valarie Pais. R1 was discovered at the bottom of a steep hillside on the evening of Sunday, August 24, 2025, according to the Tuolumne County Sheriff’s Office, which led search and rescue efforts. LPAs Lindstrom and Moleski reviewed R1’s service plan, dated November 22, 2024. The service plan indicates that R1 had a “history of wandering outside the community,” and that “health and safety may be jeopardized.” LPAs Lindstrom and Moleski reviewed R1’s LIC 602, which was signed by a physician on January 6, 2025. The LIC 602 does not indicate that R1 had a history of wandering behaviors. However, the actual exam of R1 took place on September 24, 2024, according to the LIC 602, which is before the aforementioned service plan identified a significant change in R1’s behavioral expressions. LPA Moleski asked Pais if R1’s physician was notified of the behaviors noted in the service plan. Pais said she was not aware of any such notification, and said that resident’s physicians should be notified if there is a significant change in condition. LPA Moleski spoke with the facility’s resident care director (S1), who had modified the service plan as of April 15, 2025. S1 said they were not aware of any such behavioral expressions. S1 said that R1’s physician should have been notified in the event that these behavioral expressions were identified. [continued on 809-C] LPAs Moleski and Lindstrom provided Pais an opportunity to acquire documentation showing that R1's physician was notified. Pais was unable to provide such documentation during this visit. 22 CCR Section 87755 states that "the licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours." 22 CCR Section 87463(e) states that “the licensee shall immediately, or as soon as reasonably possible, bring any significant change in condition … to the attention of the appropriate licensed medical professional … documentation of such communication shall be added to the resident’s record…” This facility is hereby cited per 22 CCR Section 87463(e). An exit interview was held with Pais. Appeal rights and a copy of this report were left with Pais.the state’s words, verbatim · CDSS document, Aug 27, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(e) · Plan of correction due date: Aug 28, 2025

“The licensee shall immediately, or as soon as reasonably possible, bring any significant change in condition, as defined in Section 87101, Definitions, to the attention of the appropriate licensed medical professional and if applicable, other specialized care provider. Documentation of such communication shall be added to the resident's record and shall include: …” This requirement was not met as evidenced by: Based on interview and record review, no documentation exists to suggest that a significant change in condition, documented on R1’s service plan dated to November 2024, was communicated to R1’s physician.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Licensee agrees to provide staff trainings on the topics of elopement and notification procedures. Licensee agrees to provide LPA Lindstrom a plan regarding these scheduled trainings by POC due date.

Type of visit: Case Management - Deficiencies

On 06/18/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived for an unannounced for a Case Management meeting. The LPA met with Valarie Pais, the Designated Facility Administrator (DFA), and explained the purpose of the visit. The purpose of the visit was to discuss the notification that the Department had received that there was a nanny cam set up and recording in a resident room. The DFA stated that a staff caregiver notified her of the video camera in R1's room on 06/03/2025. The DFA, who was off-site at the time, called the Director of Health and Wellness (DHW) Kayla Varney and directed her to call the resident's family to inform them that the video camera in the resident's room was against regulation. The DHW called the family early evening to let them know this and that staff was going to remove the camera immediately. The DFA stated that Resident Care Director Rachel Cole removed it from the resident's room by 6 PM. The DFA stated that on 06/07/2025, one of R1's granddaughters contacted her to inform her of possibly suspicious activity in their grandfather's room that was captured on the camera. She forwarded two videos to the DFA. The first video was time stamped 06/03/2025 at 2:41 PM and showed staff looking in the resident's kitchen cabinets and counters. The DFA clarified with Kristin that this was kitchen staff looking for dirty dishes, as R1 received food service in his room. The second video was time stamped 06/03/2025 at 5:36 PM and showed staff taking an Ensure from the resident's kitchen. The DFA conducted an investigation and determined that this was a caregiver that took the Ensure without authorization. The investigation resulted in the employee's termination. The DFA stated that the resident's family requested permission to reinstall the video camera in the resident's bedroom so that they can see their grandfather more often. The DFA inquired what was involved in getting permission for this. Senior Executive Director Alyssa Sellers of Milestone Retirement joined the conversation by cell phone. The LPA informed them that the facility must submit an exception waiver request for a video camera to the Department and that its Plan of Operations and Admission Agreement would need to be updated accordingly if approved. The LPA stated that approval of an exception waiver for a video camera was granted by the Department's Program Manager. The LPA and the DFA toured the R1's apartment. The LPA observed that the camera was no longer in the apartment. The LPA toured the Med Tech room and observed the video camera in storage there. Based on observations made during the inspection of the facility and an interview with the Administrator, the Department has found the facility to be noncompliant and has cited it for one deficiency. An exit interview was conducted, and Appeal Rights were discussed with the DFA. Copies of this LIC 809/LIC 809D report and appeal rights were provided to the DFA.the state’s words, verbatim · CDSS document, Jun 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211 · Plan of correction due date: Jun 18, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency…:(1) A written report…within seven days of the occurrence…(D) Any incident which threatens the welfare, safety or health of any resident. This requirement was not met as evidenced by: Based on interview and record review, the Licensee did not ensure that a LIC624 was submitted to the Department notifying it of the termination of an employee for theft from a resident.the state’s words, verbatim · CDSS document, Jun 18, 2025

Plan of correction: The Designated Facility Administrator shall submit a LIC 624 documenting the incident to the Department. This report can be sent to the LPA Triel Ellen Lindstrom at ellen. lindstrom@dss.ca.gov.

Type of visit: Case Management - Deficiencies

On 05/06/2025, Licensing Program Analyst (LPA) Renee Campbell and Triel Lindstrom arrived to the facility unannounced regarding the facility camera policy. LPA Campbell met with Administrator Valerie Pais and explained the purpose of the visit. During the visit, LPA Campbell and Triel Lindstrom discussed the Safely You camera system with the administrator. Per Administrator Pais, Safely You is a camera system that uses Artificial Intelligence and sensors to identify when a resident has fallen. The cameras do not record sound. Per the administrator, Safely You does not save any data unless it is detected that a resident has fallen. At which time, the system will save the prior 8 minutes before the fall. LPA Campbell asked if the cameras in the rooms will be removable upon resident request. Administrator Pais stated she would need to investigate this option with Safely You. On 04/17/2025, a directive was issued by the Department to the facility to turn off the Safely You system. However, per the administrator, the facility did not know this included Memory Care as well. Once clarified, Administrator Pais agreed to turn off the Safely You system for Memory Care and she illustrated how the administrator can turn off the Safely You surveillance systems online. The facility can turn off the system through the Safely You website or request the company to do it for them. To verify the system has been turned off for all the rooms, the facility will request that Safely You turn off the system for Memory Care and email confirmation to the Department. The facility will also request verification from Safely You that data not related to a fall does not exist and cannot be retrieved. Per Administrator Pais, the cameras in Memory Care have been live since approximately May of 2024 after obtaining consent from the resident’s Power of Attorney. But the facility has not received an approved waiver for cameras in residents rooms in Assisted Living or Memory Care. There are currently 34 rooms with cameras installed but inactive in Assisted Living and 10 rooms with cameras installed that were made inactive during today's visit in Memory care. In summary, as part of their plan of correction, LPA Campbell and Triel Lindstrom requested that the facility will submit a waiver, plan of ops and admission agreement addendums for Memory Care and Assisted Living regarding use of Safely You in resident’s rooms. The facility will also request information from Safely You regarding optional removal of cameras from resident rooms and verification that data is not retained and cannot be retrieved. Such information will then be emailed to Triel Lindstrom at ellen.lindstrom@dss.ca.gov. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit. An exit interview was conducted, and copies of the report and appeal rights left.the state’s words, verbatim · CDSS document, May 6, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: May 20, 2025

87468.2 Additional Personal Rights of Residents ...residents in ... residential care facilities for the elderly shall have all of the following personal rights: ... a reasonable level of personal privacy in accommodations. This requirement is not met as evidenced by: Based on interview, residents were not permitted a reasonable level of privacy in their private bedrooms due to the presence of cameras in their rooms which poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Licensee agrees to provide verification from Safely You that data is not retained outside of falls and will provide waiver requests, plan of ops and admission agreement addendum regarding camera use in residents rooms. Items will then be emailed to Triel Lindstrrom at ellen.lindstrom@dss.ca.gov.

Type of visit: Case Management - Other

On 05/06/2025, Licensing Program Analysts (LPAs) Triel Ellen Lindstrom and Renee Campbell arrived unannounced to this facility to conduct a case management visit. LPAs met with Facility Designated Administrator (FDA) Valarie Pais and explained the purpose of the visit. The purpose of this visit was to discuss the 30-day eviction notice issued by the facility against R1 on12/20/2024. On 04/28/2025, the Department issued a statement that it did not support the eviction. FDA Pais stated that R1 shared a private apartment with her husband. According to FDA Pais, R1’s husband was responsible for the base rent of the apartment and R1 was responsible for an additional fee as the second person in the apartment. FDA Pais stated that when R1’s husband passed away last year, R1 began to be charged the full amount of the rent for the unit, as outlined in the rental agreement. She stated that neither R1 or her Power of Attorney (POA) was sent a notification of the rent increase nor an addendum with this information to sign. LPA Lindstrom inquired about the requests for a smaller, more affordable room that R1’s POA stated she made in a 01/08/2025 email to FDA Pais stated that she told R1's POA that there were no smaller, more affordable rooms available at the time of these requests. FDA Pais stated that the facility attempted to collect an unpaid balance in August 2024 and that when this attempt was unsuccessful, the facility discussed a 30-day eviction notice with LPA Maja Jensen. At this point in the conversation, FDA Pais brought Carly Taylor, Chief Clinical Officer for Milestone Retirement into the conversation by cell phone. Both FDA Pais and CCO Taylow stated that it was their understanding that LPA Jensen had approved the 30-day eviction notice after reviewing the facility’s draft notice and providing recommendations for change. FDA Pais forwarded email correspondence between herself and LPA Jensen dated 10/02/2024 to LPA Lindstrom, in which LPA Jensen stated, ‘While it does appear to be a legal eviction I did recommend some changes.” Upon review of the facility's revised 30-day eviction notice, LPA Jensen said, "This looks great," in a 10/30/2024 email. FDA Pais and CCO Taylor stated that it was their understanding that they had followed Department advice in terms of the assistance the facility offered R1 in finding alternate placement by providing the links to resources that LPA Jensen had sent in her 10/02/2024 email, as well as by providing R1's POA with information about two local residential facilities that accept Medicare and Medical. FDA Pais stated that R1’s POA has not made arrangements with an alternate facility nor paid off R1’s unpaid balance. LPAs Lindstrom and Campbell then discussed with FDA Pais and CCO Taylor what type of assistance R1 needs at this time. LPAs Lindstrom and Campbell recommended that the facility take additional steps to find R1 an alternate placement. FDA Pais stated that the facility will call local facilities to check on availability, help arrange assessments and alternate placement and provide them with the needed clinical information. FDA Pais stated that the facility will contact the Long-Term Ombudsman for additional guidance on how to support R1. LPAs Lindstrom and Campbell discussed the three steps that the Department outlined for the facility to follow. These three steps are drafting and getting a signature on an addendum to the original rent agreement that notifies R1 of the new rental agreement amount, making an offer to stay in a shared room at an alternate rate, and making additional efforts to find R1 alternative placement. The facility will consult with their Chief Compliance Officer regarding documentation of these steps and notify the department of any questions they may have. Any documentation shall be emailed to LPA Lindstrom at ellen.lindstrom@dss.ca.gov. The department may return at a later date to determine if further action is needed.the state’s words, verbatim · CDSS document, May 6, 2025

Allegation investigated: Facility staff did not provide timely medical care

On 02/26/25, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to present findings regarding a Complaint. LPA Campbell met with Valerie Pais and explained the purpose of the visit. Regarding the allegation that staff did not provide timely medical care, on 09/10/24, a complaint was filed with the Department alleging neglect/lack of care and supervision. During the course of the investigation, the Department conducted interviews with staff and reviewed files for S4 and R1. When interviewed, staff reported that S4 did not check on R1 and other residents when requested due to COVID-19. Based on these findings, it was SUBSTANTIATED that staff did not provide timely medical care. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided. Substantiated A civil penalty in the amount of $500 is hereby assessed due to a violation resulting in injury to a resident, as described above and is cited on the LIC 421IM page. Additional civil penalties are currently being evaluated by the Department, pursuant to Health and Safety Code § 1569.49(f). An exit interview was held with Valerie Pais, Administrator . Appeal rights, a copy of the civil penalty assessment, and a copy of this report were left with Valerie Pais.the state’s words, verbatim · CDSS document, Feb 26, 2025 · control 27-AS-20241002164831

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312 · Plan of correction due date: Mar 10, 2025

1569.312 Basic services requirements: Every facility required to be licensed ... shall provide at least the following basic services: Monitoring the activities of the residents... to ensure their general health, safety, and well-being. This requirement was not met as evidenced by : Based on interviews and records review, the licensee did not ensure S4 monitored R1 to ensure R1’s general health and safety which poses an immediate Health, Safety and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 26, 2025

Plan of correction: The facility will conduct in-service training regarding when to call emergency services when the med-tech or other supervisor does not respond. And to remind staff that they cannot decline to provide care during outbreaks. The facility willl provide sign in sheets for this training by POC date.

Allegation investigated: Staff does not ensure facility is kept free of odors Staff does not ensure residents rooms are kept in clean, sanitary conditions Staff do not ensure residents are spoken to in an appropriate manner

On 02/26/2025, Licensing Program Analyst (LPA) Renee Campbell arrived at the facility unannounced to conduct an investigation on a complaint that was submitted to the Department on 02/24/25. LPA Campbell met with Valerie Pais, Administrator and explained the purpose of the visit. During the investigation, LPA Campbell observed rooms, hallways and stairwells, reviewed client and staff rosters and interviewed a random selection of residents. Regarding the allegation that staff does not ensure the facility is kept free of odors, LPA Campbell observed odors in two of the six rooms selected for observation. The rooms were observed to be clean without obstructions but food was observed to have been left out in R2's room for a pet cat and R3 had been recently changed. Because residents prefer to keep their doors closed, LPA Campbell observed no odors in the facility hallways or common areas. Report continued on 9099-C Unsubstantiated Regarding the allegation that staff does not ensure residents rooms are kept in clean, sanitary conditions, of the six rooms LPA Campbell observed no pests or obstructions were observed on the floor. Furniture was in good repair and the kitchens and bathrooms were clean and clear of any debris. Of three residents interviewed (R7, R5, R8), all reported weekly visits by staff to clean their rooms and collect their laundry and a willingness by staff to remove additional trash at their request. Regarding the allegation that staff speak to residents in an inappropriate manner, of the three residents interviewed (R7, R5, R8) none reported being spoken to inappropriately or hearing other residents being spoken to inappropriately or shouted at. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore this allegation is UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, no deficiencies cited. Exit interview was held and a copy of report was given to Valerie Pais, Administrator.the state’s words, verbatim · CDSS document, Feb 26, 2025 · control 27-AS-20250224103421

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 01/08/24, Licensing Program Analyst Renee Campbell arrived to the facility unannounced to complete an annual inspection. LPA Campbell met with Valerie Pais, Administrator (7018063740) and explained the purpose of the visit. Upon entry, LPA Campbell observed a client playing the piano for other residents who complimented their skill. Staff welcomed LPA Campbell to the facility and directed them to sign in and for a digital fever check. The facility is a Residential Care Facility for the Elderly and is licensed for clients age 60 and over. The facility has a capacity of 135 non-ambulatory residents. There may be 35 bedridden residents and there is a hospice waiver granted for 12. The building consists of five floors with Memory Care and Assisted Living in their own units. LPA Campbell observed memory care rooms that were furnished appropriately. Bathrooms were in the hall and hot water was measured at 116.9 degrees Fahrenheit (F). Clients in Assisted living had their own bathrooms and hot water was measured at 116.1 degrees which is within the requirement of 105 and 120 degrees F. In the Assisted Living wing, notes of appreciation from residents were displayed for staff. LPA Campbell observed the dining room in the Memory Care unit. All pathways were free of obstruction. Ongoing construction was observed in the non-perishable storage rooms as mentioned in the 11/06/24 812 Notification from the facility. Construction areas included the storage rooms and outside the kitchen entrance. Both areas are staff only and clients are unable to access them. Food service for clients have not been disrupted. LPA Campbell reviewed the fire drill log for October and November. Fire drill procedures and the sign in sheet for all participants were included. Fire extinguishers were last inspected on 02/07/2024. Thermostats were set at 72 degrees F. There were 5 residents files and 4 staff files that were reviewed and found to be complete. LPA Campbell consulted with administrator regarding client and staff files. It was suggested that files be consistent in organization and a checklist of items to be file was provided to ensure files were complete. Administrator was also reminded to continually update the Guardian Roster for the facility and remove staff who are no longer employed with them. Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted with Valerie Pais, Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 8, 2025

Type of visit: Case Management - Incident

On 01/08/24, Licensing Program Analyst Renee Campbell arrived to the facility unannounced to complete an annual inspection. LPA Campbell met with Valerie Pais, Administrator (7018063740) and explained the purpose of the visit. Upon entry, LPA Campbell observed a client playing the piano for other residents who complimented their skill. Staff welcomed LPA Campbell to the facility and directed them to sign in and for a digital fever check. On 12/30/24, an Unusual Incident Report (UIR) was received regarding a possible sexual assault that occurred. On 12/28/24 staff responded to R1’s cries for help from their room and their room alarm. Staff 1 (S1) found R1 laying on the bed with R2 on top of them. While R2 was assessed at the hospital, there is no report of medical care for R2. Because the UIR does not clarify if there was an attempted sexual assault, LPA Campbell conducted a case management. When contacted, R1’s responsible party (R3) reported that R2 had many incidents of attempting to go into R1’s and other residents’ rooms and lay on their beds or stare out their windows. On the day of the incident on 12/28/24, when R3 arrived, R1 had fallen asleep and R3 refused further medical care. R3 reported that R1 did not remember the incident and R3 did not believe R1 had been sexually assaulted. Per S2, when R2 attempted to strangle a staff member. The facility then sent R2 to the hospital for reassessment and prepared to submit an eviction request to licensing. However, before that occurred, the hospice case worker found a new placement. R2’s family then came and removed his belongings the next day. R2 was removed soon after this incident due to violent outbursts with staff. Before R2's removal, the administrator consulted with licensing staff and attempted to change medication, care plans and use 1 on 1 care. Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted with Valerie Pais, Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 8, 2025

Allegation investigated: Facility staff served unsafe food

On 12/2/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open a complaint investigation in to the above listed allegation. LPA Jensen met with Executive Director Valerie Pais and explained the purpose of today's visit. LPA Jensen interviewed the Executive Director who advised that residents began presenting with gastrointestinal (GI) symptoms on 11/26/24 in the PM. By 11/29/24 there were 26 residents and 13 staff members with GI symptoms. As of this date there are 33 residents with GI symptoms and 25 staff. Residents are returning from the hospital with discharges paperwork that states they have an unspecified gastrointestinal virus. In the presence of LPA the Executive Director contacted the Administrative Director of Acute Services with Adventist hospital who confirmed that stool samples were taken from some residents and a panel of testing was conducted to rule out food bourne illness. Tests to date have come back negative for food bourne illness. Continued on LIC 9099C... Unfounded No testing was conducted for Norovirus. LPA Jensen inspected the kitchen. LPA Jensen did not observe any expired food and the area appeared sanitary. Freezer and refrigerator temperatures were within the required range. According to the Executive Director the facility underwent a Crandall audit of the kitchen on 11/29/24 and no deficiencies were observed. The Executive Director will be forwarding this report to the Department by 12/6/24. Based on LPA Jensen's discussion with the Hospital Director who confirmed food bourne illness has been ruled out and based on LPA Jensen's inspection of the kitchen the allegation of Facility staff served unsafe food is UNFOUNDED. A finding of unfounded means the allegation is false, could not have happened, or is without a reasonable basis. During the course of this visit LPA Jensen is also conducting a case management for the GI symptom outbreak. Based on a conversation with the Administrative Director of Acute Services of the local hospital the cause of the GI outbreak is suspected to be viral. LPA Jensen requested the facility GI illness/Norovirus policy. This policy is dated 3/15/22. LPA Jensen advised that all GI infection control procedures should be implemented effective immediately. The procedures include but are not limited to the following: -Obtaining a stool culture for verification of Norovirus -Canceling group activities -Closing the dining room and implementing room delivery for meals -Posting "Infectious Outbreak" signs outside of the community to notify visitors -No new admissions -Continue all precautions for a full week after last reported case The facility is also in the process of renovations near the dining area for mold mitigation. LPA Jensen requested the facility obtain air quality readings to retain on file conducted by the vendor contracted with for environmental hazard reduction. The facility will notify the Department of the results of the Norovirus testing and send a line list to the Department until the outbreak has resolved and they are cleared by Public Health. No deficiencies are being cited. An exit interview was conducted with the Executive Director and facility Chief Clinical Officer, Carley Taylor.the state’s words, verbatim · CDSS document, Dec 2, 2024 · control 27-AS-20241127112128

Type of visit: Case Management - Incident

On 11/7/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management regarding some recent incidents. LPA Jensen met with Executive Director Valerie Pais and explained the purpose of today's visit. The facility recently experienced a plumbing issue. Plumbers were called immediately upon recognizing the problem. The plumbers were able to identify the cause of the issue. The insurance company was called and determined the issue to be a covered a loss and action was initiated to mitigate damages and complete any necessary repairs. A letter was sent to all resident responsible parties prior to work commencing and Licensing was notified in a timely manner. LPA Jensen toured the areas being worked on and observed appropriate measures being taken to ensure the safety of residents. All work areas are adequately cordoned off and tools and toxins are being kept inaccessible to residents in care. LPA Jensen also discussed an incident that was reported wherein a spouse visiting a resident was observed by a care provider physically abusing the resident. No significant injuries were sustained by the resident. The care provider took immediate action and notified the med tech on duty. The med tech called the Sheriff who responded and a report was taken. The facility also notified the resident's daughter, the resident's physician, the hospice care provider, Adult Protective Services and the Ombudsman. A temporary protective order was initiated. The resident will be placed on increased monitoring. All reporting was completed in a timely manner and it would appear that all appropriate action was taken by the facility staff. No deficiencies were observed during the course of this visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 7, 2024

Allegation investigated: Staff do not ensure call signal system requests are answered in a timely manner

On 10/23/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue an investigation in to a complaint investigation related to the above listed allegations. LPA Jensen met with Executive Director Valerie Pais and explained the purpose of today's visit. During the course of the investigation LPA Jensen reviewed care response logs and emails between the responsible party for resident 1 (R1) and facility staff. During the course of an interview with the Executive Director, LPA Jensen asked what a reasonable amount of time would be for staff to respond to a resident that activates their call pendant. The Executive Director responded that response times can vary depending on what else is happening in the facility such as a resident emergency for example but generally a call should be responded to within 15-20 minutes. LPA Jensen reviewed response logs for R1 for the week of 7/21/24 to 7/27/24. During that period of time R1 activated the call pendant 16 times and 11 of 16 times the response took more than 20 minutes. Continued on LIC 9099C.... Substantiated LPA Jensen also conducted an interview with the Executive Director. The Executive Director explained that the facility did not have a physician's order for one of resident 1 (R1's) medications upon move in. In addition there was confusion regarding who would administer the medication. R1's family wanted R1 to self administer medication however R1 was unable to do so effectively upon initial assessment by the facility nurse. The records reviewed support the statements made by the Executive Director. The medication administration records show that facility staff attempted to obtain the physician's order for the medication in question within 1 day of R1's arrival. The emails reviewed also show that R1's family member had brought medication in after move in that was not sent with R1 upon arrival. While there does appear to be a misunderstanding regarding a medication that R1 should be receiving there is insufficient evidence to show any negligence on behalf of facility staff. Based on the records reviewed and the interview conducted the allegation of "Staff did not ensure medications were dispensed as prescribed" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have occurred, the preponderance of evidence does not prove it. Allegation 2: Staff did not ensure residents incontinence care needs were being met LPA Jensen conducted a site tour and observed approximately 30 residents engaged in various activities. All residents observed appeared to be well groomed. LPA Jensen also interviewed 8 residents, 3 staff members, a resident family member and a hospice worker from an outside agency. All residents interviewed stated that their care needs are met in a timely manner. All others interviewed stated residents received frequent and timely incontinence care. One staff member said there have been occasions where residents had been left in soiled briefs but that this occurred only about 2 x a month and the situation was improving. Based on the interviews conducted and LPA Jensen's own observations the allegation of "Staff did not ensure residents incontinence care needs were being met" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have occurred, the preponderance of evidence does not prove it. An exit interview was conducted and a copy of this report was provided. LPA Jensen also reviewed an email exchange between the resident care director and a responsible party for a resident. In the email the resident care director advised that the facility's goal is to have staff respond to pages within ten minutes. Based on the call log showing response times to be in excess of the facility's goal or expectations more than 68% of the time the allegation of "Staff do not ensure call signal system requests are answered in a timely manner" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Deficiencies are being cited on the LIC 9099D. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 23, 2024 · control 27-AS-20240807163148

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Oct 23, 2024

Basic Services Basic services shall at a minimum include: Personal assistance and care as needed by the resident... with those activities of daily living ...This requirement was not met as evidenced by: Based on LPA Jensen's review of the call log response times, R1 did not receive personal assistance when needed and waited excessively based on the facility's own standards. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 23, 2024

Plan of correction: The facility has conducted in-service training in August of 2024 with staff and implemented an enhanced call response system which has reduced response time as verified by LPA Jensen. No further plan of correction is required.

Type of visit: Post Licensing

On 7/2/24 at approximately 1:45pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a post-licensing inspection. LPA Jensen met with interim Executive Director Valerie Pais and explained the purpose of today's visit. LPA Jensen inspected the physical plant including the common areas, kitchen, resident rooms and memory support unit. The facility recently underwent some renovations that include new flooring, new paint and new furniture. The facility was observed to be sanitary and all furniture was in good repair. There was 2 days of perishable food and 7 days of non-perishable food. The Ansul system was last serviced in March of 2024 and is in compliance. The kitchen maintains documentation on residents that require special diets that is readily accessible by the kitchen staff. The resident rooms were equipped with all required furniture. LPA Jensen interacted with several residents during the visit, all of whom stated they are satisfied with the accommodations and care they are receiving. The assisted living section of the facility has call signals in the living area, bedroom and bathroom of each unit. LPA Jensen toured the Memory Support Unit. The memory support unit has a monitoring system in place for resident falls within the individual living units. The bathroom water temperature was measured in a main hall bathroom used by residents at 112 degrees and is in compliance. The thermostat in the main hall was set at 76 degrees and is in compliance. LPA Jensen observed several residents engaged in activities. LPA Jensen observed a large board listing the daily activities that included visits from support animals, chair exercises, Bingo, Pokeno and movie night. The facility is currently recruiting for an on staff nurse. LPA Jensen reviewed physician reports for residents that are insulin dependent. 1 of 3 residents are unable to administer their own glucose testing and insulin injections. Technical assistance was provided. The facility was observed to be in substantial compliance. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 2, 2024

Allegation investigated: Staff do not ensure that resident's hygiene needs are being met. Facility is charging resident for services not provided.

On 4/29/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegation. LPA Jensen met with Executive Director Aimee Jo Mattson and explained the purpose of today's visit. During the course of the investigation the Department conducted interviews with a Home Health Nurse, the facility Regional Nurse, the Executive Director and resident 1 (R1). The Department also reviewed documentation that includes an Admission Agreement, Needs and Service Plans, Home Health documentation, facility policy, in-service training records, and resident chart notes. Based on the facility bathing policy, "staff will ensure resident's participation to bathe or shower on a routine basis...Twice weekly and as needed will be scheduled." Based on LPA Jensen's review of the skin observation sheet R1 was bathed 6 times in ten weeks. Substantiated The resident was admitted in September of 2023 but did not have hygiene added to the needs and service plan until January of 2024. Documentation indicates that R1's wounds were miscategorized as pressure wounds but were actually due to urinary incontinence. R1's physician report makes no indication of cognitive impairment for R1. During the course of an interview with R1, R1 denies any neglect by staff. Based on the records reviewed and interviews conducted the allegation of "Resident developed pressure wounds while in care due to neglect" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation my have happened, the preponderence of evidence does not prove it. An exit interview was conducted and a copy of this report and appeal rights were provided. The skin observation sheet also noted that R1's toenails or finger nails or both needed clipping on 5 of 6 forms during the period between 12/6/23 through 2/14/24. On 12/27/23 a Home Health Nurse completed an Outside Agency Documentation form and identified resident hygiene as a concern. During the course of an interview R1 confirmed that she was not assisted with showers twice weekly and that there have been occasions where she has called for assistance with no response for up to an hour. The home health documentation reviewed shows that on multiple occasions, including after hygiene was added to R1's care plan, a home health visit was conducted and R1 was observed to be soiled upon their arrival. Based on interviews conducted and the documentation reviewed the allegation of "Staff do not ensure that resident's hygiene needs are being met" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. The Department also conducted a review of the admission agreement, pre-placement appraisal and 3 needs and service plans. Based on the documentation reviewed and interviews conducted R1 was not receiving 2 showers per week after hygiene services were added and billed under the needs and service plan therefore the allegation of " Facility is charging resident for services not provided" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Deficiencies are bing cited pursuant to the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report, a confidential names list and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 29, 2024 · control 27-AS-20240208161140

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 27, 2024

Additional Personal Rights of Residents in Privately Operated Facilities ...To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by the documentation reviewed reveals that the resident was being charged for hygiene services that were not being administered. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Apr 29, 2024

Plan of correction: The Licensee agrees to conduct an in-service training and send proof of completion by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Apr 30, 2024

Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by: Based on records reviewed and interviews conducted the facility did not meet the hygiene needs of R1 which lead to the development of open wounds. This poses and immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Apr 29, 2024

Plan of correction: Effective 2/23/24 the Licensee has filled a vacant health and wellness director position who now provides oversight for the resident care director and memory care director and does all assessment for new residents. No further plan of correction required.

Type of visit: Prelicensing

On 12/28/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue the pre-licensing visit commenced on 12/12/23. LPA Jensen met with Executive Director Aimee Jo Mattson and explained the purpose of today's visit. During the pre-licensing visit conducted on 12/12/23, LPA Jensen requested that the facility ensure all chemicals or cleaning solutions be locked and inaccessible to clients in care. LPA Jensen also requested a diabetic care plan be submitted for Department review. LPA Jensen received and reviewed the diabetic care plan and determined it to be in compliance. In addition the facility has contracted with a medical doctor for in house services commencing on 1/4/24. In addition LPA Jensen reviewed Physician communication forms for current residents requesting new orders clarifying the diabetic management need for assistance specifics. LPA Jensen toured the resident rooms to check for storage of cleaning solutions and found the rooms to be in compliance. LPA Jensen checked the laundry facility and found it to be secured. The facility was observed to be in substantial compliance and has passed the pre-licensing inspection. A component III presentation was conducted. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 28, 2023

Type of visit: Prelicensing

On 12/12/23 Licensing Program Analysts (LPAs) Maja Jensen and Kesha Lewis arrived at facility unannounced to conduct a pre-licensing visit for a change in ownership. LPAs Jensen and Lewis met with Executive Director Aimee Jo Mattson and explained the purpose of today's visit. LPA Jensen toured the facility including grounds, physical plant. The grounds were observed to be maintained and all paths were clear of debris. LPA Jensen toured 5 resident rooms and observed all to be equipped with the required furniture including chairs, lamps, and night stand. The water temperature in resident bathrooms and kitchenette was measured at 118 degrees which is in compliance. Unsecured cleaning chemicals were observed in resident room cabinets in the assisted living portion of the facility which included Lysol cleaner, Spray and Wash and Liquid Gold wood cleaner. The laundry room was found to be unlocked. LPA Jensen reviewed the disaster plan and confirmed it to be in compliance. The facility has hard wired smoke detectors and a sprinkler system. The carbon monoxide detector was tested and determined to be in good working order. The fire extinguisher was last serviced in March of 2023 and is in compliance. One end of the building is equipped with a back up generator. The entire building has emergency lighting throughout the common areas. The first aid kit was observed to be complete. All required postings were observed to be displayed in a prominent location. The Pre-Licensing tool was used during the course of this inspection. LPA Jensen toured the kitchen. The facility maintains a 7 day supply of non-perishable food and a 2 day supply perishable food. All food was labeled and no expired food was observed. The kitchen was observed to sanitary. The kitchen chemicals were in a separate locked storage room. The freezer and refrigerator temperature was in compliance. Kitchen staff are appropriately trained and certified. Continued on LIC 809C... LPA Jensen inspected the medication room. LPA Jensen asked the medication technician to open the locked medication cart. Syringes were observed in the medication cart. LPA Jensen asked the medication technician if any residents are insulin dependent residents and was advised that there are. LPA Jensen asked who administers the insulin and was advised by the medication technician that residents administer their own insulin with hand over hand assistance by staff. LPA reviewed the LIC 602 for Resident 2 (R2) which states the resident is unable to administer their own medication or injections and cannot conduct their own glucose testing. The facility has not passed the pre-licensing inspection and has been asked to submit a diabetic care plan and to remove all chemicals from resident rooms. The Executive Director anticipates having completed the requested items no later than 12/22/23. An exit interview was conducted and a copy of this report, appeal rights and an LIC 811 was provided.the state’s words, verbatim · CDSS document, Dec 12, 2023