Skypark Manor

Type of visit: Case Management - Legal/Non-compliance

On September 02, 2026, at 1:30 PM, Licensing Program Analyst (LPA) Sulma Lopez and Licensing Program Manager (LPM) Arielle Pascua arrived unannounced at the facility to conduct a quarterly inspection due to non-compliance conference held on 04/30/2026. LPA and LPM met with Administrator (A1) Rabinder Singh and explained the purpose of today's visit. At 1:15 PM LPA and LPM toured the 1st and 2nd floor of the facility with A1. LPA observed several areas of the flooring were raised and bubbling, making an uneven walking surface. The elevators were serviced annually on January 31, 2026. Resident bedrooms were furnished with beds, dressers, and P-TAC air conditioning units in each room. LPA observed Resident 1's (R1) room to have a strong urine smell.LPA observed that the room is furnished with carpet flooring. A1 asked Staff 1 (S1) to shampoo the carpet thoroughly after the smell was identified. LPM Pascua asked what types of support the facility conducts to ensure that the resident's incontinence needs are being met. A1 stated that the resident does not utilize incontinence briefs, staff remind him to toilet independently, but it is difficult because he has dementia. A review of R1's assessment was conducted, it was revealed the resident is incontinent with their bladder and bowel. It was learned that the facility is responsible to ensure the resident is prompted to use the restroom every 2 hours or as needed. In addition, a review of the facilities procedures for daily cleaning states that the facility staff should ensure the resident bedrooms are odor free. The facility hallways were observed to be free of clutter and the walkways were free of obstructiosn. The facility temperature was 75 degrees. LPA observed the ceiling tiles from a previous leak were still present in the facility. The tiles have been patched to fill in gaps and LPA observed water damage stains present. Continued on LIC 809-C. LPA and LPM toured the upstairs activity room which was under renovation from the previous leak. It was learned that the roof has been repaired and additional work is being completed in the activity room. LPA and LPM identified 2 stairways at the end of each hallway equipped with an emergency chair. The exterior of facility was clear of debris. All outdoor passageways were kept free from obstruction. LPA and LPM toured the dining area and facility kitchen. The areas were observed to be clean, free of odors, and free of hazards. The dining room area contained enough seating for the current census. A meal menu was posted in the facility kitchen. LPA observed food supplies included 2 days of perishables and at least 7 days of non-perishable food items. At 2:30 PM, LPA and LPM conducted records review of the facility's Policy and Procedures Manual, Fire Drill Logs, Resident Records, and Emergency Disaster Plan. The last fire drill was conducted on August 6, 2026. It was learned that since April 30, 2026, the facility has changed and implemented several policies and procedures pertaining to their maintenance and operation and emergency disaster planning, however the facility has not reviewed their Emergency Disaster Plan since December 29, 2025 including but not limited to instructions on how to utilize emergency evacuation chairs. Based on the observations made during this visit, the following deficiencies are being cited during this visit. An exit interview, appeals rights, and a copy of this report was provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Sep 2, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 18, 2026

87303 Maintenance and Operation (a)- The facility shall be clean, safe, sanitary and in good repair at all times. The requirement is not met as evidenced by: Based on observation, interviews, and records review, the licensee did not ensure that the facility floors did not have bubbling and lifting, making an uneven walking surface which poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: The facility agrees to create a repair plan detailing the scope of the repairs and plan to minimize disruptions to residents in care. The facility agrees to send the finalized plan to the Department by Friday October 2, 2026 by 5PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87625(b)(3) · Plan of correction due date: Sep 18, 2026

87625 Managed Incontinence- (b)... the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on observation, interviews, and records review, the licensee did not ensure that R1's room was free of odor from incontinence which poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: Facility agrees to conduct an in service training with care staff on proper incontinence care procedures. The facility agrees to email a copy of the in service training to the Department by Friday September 18, 2026 by 5:00pm.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(d) · Plan of correction due date: Sep 18, 2026

1569.695 Emergency Plans- (d) A facility shall review the plan annually and make updates as necessary... The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated... This requirement is not met as evidenced by: Based on observation, interviews, and records review, the licensee did not update and sign the Emergency Disaster Plan following the implementation of new procedures after April 30, 2026 which poses a health, safety, or personal rights risk for residents in care.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: The facility agrees to review and update the Emergency Disaster Plan. The facilty agrees to send a signed copy of the updated plan to the Department via email by Friday, September, 18, 2026 by 5pm.

Type of visit: Case Management - Legal/Non-compliance

A Non-Compliance Conference (NCC) was conducted via Microsoft Teams on this day, April 30, 2026, at 1:30 PM, by the Sacramento South Regional Office. Present at the meeting were Regional Manager (RM), Stephenie Doub, Licensing Program Manager (LPM), Liza King, Licensing Program Analyst (LPA), Avelina Martinez; Facility representatives: Administrator, Rabindar Singh, Assistant Administrator, Susan McClure, CEO, Sherry Richardson, Clark Pest Control Pete Gasca. The Non-Compliance Conference process was explained during this meeting to include the administrative process. Items discussed during the Non-Compliance Conference were: Facility water temperature Pest infestation Asbestos Medication errors Roof repairs, HEP air filters, and Leaks Annual training and first aid Food service Plumbing and sewage back ups Delayed egress Fire drill Control of property/lease agreement/ Continued... Citations from the last three years: Since January 2023- Citations: 5 Type A and 14 Type B Licensee has implemented the following to bring the facility into compliance: Implement policy and procedures that will provide oversight on the following: annual training, Incidental and medical, food service, fire clearance and fire safety, water temperature safety, care and supervision, and buildings and grounds. Facility staff agree to submit the following documents to Community Care Licensing (CCLD) by May 08, 2026, by 5:00 PM: Annual training policies and procedures Fire drill logs and fire safety polices and procedures Medication audit procedures and policies Maintenance and operations audit policies and procedures regarding the following: water temperature, smoke detectors, carbon detectors, delayed egress door, pest inspections, cleaning and sanitation of the facility. Dietician reports/visits. Dietician policies and procedures Lease agreement, and documentation in regards to who is responsible for paying for facility repairs. Community Care Licensing Department (CCLD) will do the following: Increase monitoring to quarterly visits. Complete TSP referral Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager. Per California Code of Regulations (CCRs) - Title 22 no deficiencies are being cited during this visit. An exit interview was conducted with, Rabindar Singh, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents. In addition, a copy of this report will be sent out certified mail.the state’s words, verbatim · CDSS document, Apr 30, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced on April 14, 2026, at 10:01 AM to conduct a case management inspection. LPA Martinez met with Rabindar Singh and explained the purpose of the visit. The purpose of the case management is to follow up on sanitation of the facility and roofing leaks. LPA Martinez toured the facility with Rabindar Singh on April 14, 2026. During the inspection, LPA Martinez observed roofing leaks on the second floor, and plumbing sewage backup on the first floor. The plumbing sewage backup is causing a foul odor. Moreover, LPA Martinez observed food particles in common hallways. During today visit, LPA Martinez also, inspected the first floor bathroom. The first floor bathroom was not sanitary. LPA Martinez observed toilet paper on the floor and black residue on the floor. The first floor bathroom also had a foul odor. LPA Martinez also observed a live cockroach, spiders, bugs, and dead pests throughout the facility. Based on today's facility inspection, the facility is not sanitary and clean. As a result of this visit, the following deficiency 87303(a) Maintenance and Operation was cited, per Title 22 Regulations. The deficiency was cited on 809-D. Due to repeating the same violation within a twelve month period, a civil penalty is hereby assessed on today's date in the amount of $1,000.00. An exit interview was conducted with Rabindar Singh. A Copy of the LIC 809, LIC 809-D Page, LIC 421IM , and appeal rights were provided to Rabindar Singh.the state’s words, verbatim · CDSS document, Apr 14, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Apr 15, 2026

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: based on observation: The Licensee did not ensure to keep the facility clean, sanitary and free of pest for the well-being of the residents in care. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 14, 2026

Plan of correction: The Administrator agrees to contract an outside cleaning agency to conduct a deep clean of the facility and to have a pest company conduct bi-weekly pest treatments until pest infestation is cleared. Administrator agrees to email LPA Martinez pest and cleaning plan by POC date 04/15/26 by 5:00pm. Administrator agrees to email cleaning estimates by 04/20/2026 by 5:00 PM and Facility Administrator agrees to have facility deep cleaned by 04/24/2026. Facility Administrator agrees to email by-weekly pest reports starting 04/30/2026.

Allegation investigated: Facility staff are not properly addressing cockroaches in the facility.

Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on April 14, 2026, at 10:01 AM to amend the below report. LPA Martinez changed the report to reflect public. Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on April 03, 2026, at 11:15 am to initiate complaint investigation with the above allegation. LPA Martinez met with Rabindar Singh, and explained the purpose of the visit. Throughout the course of the investigation, LPA Martinez conducted interviews and inspected the facility. LPA Martinez inspected five bedroom, common areas, hallways, and kitchen. Based on today's inspection observations, it was determined the facility has a pest problem. LPA Martinez observed cockroaches in the bedrooms and common spaces. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The deficiency is cited on the LIC 9099-D page, per Title 22 Regulations. An exit interview was conducted, and a copy of this LIC 9099 report, LIC 9099-D page, and LIC appeal rights document were provided to the facility. Substantiatedthe state’s words, verbatim · CDSS document, Apr 3, 2026 · control 27-AS-20260330082225

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 6, 2026

87303 (a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on interviews and observation, the Licensee did not ensure the facility was sanitary and safe for residents in care. The facility has a pest/cockroach problem. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: Facility has hired a pest company to conduct pest treatments throughout the facility. Facility staff agrees to hire a pest company to complete a pest inspection. Implement a maintiance pest plan that includes daily cleaning in common areas and contaminated/pest bedrooms, and providing LPA Martinez Friday weekly pest updates by 5:00 PM. Weekly Updates and pest plan will begin 04/06/2026 and end on 05/06/2026. Weekly updates shall be emailed to LPA Martinez. Facility staff agrees to email pest inpsection report on 04/13/2026 by 5:00 PM.

Type of visit: Case Management - Other

On 12/29/25, Licensing Program Analyst (LPAs) Cynthia Tamayo made an unannounced case management visit to this facility to conduct a case management visit. LPA met with Susan McClure (S2), Dietary Manager and assistant administrator and explained the purpose of today's visit. Administrator, Sherry Richardson (S1) and Rabindar Singh (S3). Current administrator, Sherry Richardson (S1) was not present during this visit. LPA discussed the plan of correction deficiencies cited 12/18/25: -87405 Administrator - Qualifications and Duties (a); S2 stated an updated LIC 610 will be emailed to LPA by end of day 12/29/25. The administrator will be changed to S3, The request will be submitted to licensing by 12/30/25. -87203 Fire Safety has been cleared. -S2 stated the patio repairs are completed and ready for re-inspection from code enforcement. the roof repair is expected to start in April 2026 and no contract has been completed as of this date. The roof repair will consist of re-roofing and not re-patching. LPA followed up on incident report received by the Regional Office on 12/19/25. R1 had an unwitnessed fall that occurred on 12/17/25. S2 stated that staff reviewed video footage and saw that dementia resident 2 (R2) pushed resident 1 (R1) due to R1 trying to enter their room. S2 stated R1 was sent out to the emergency room and is still in the hospital and it seems like they have a fracture on hip. S2 stated an amended incident report was sent to regional office on 12/29/25. The incident was unintentional Reporting requirements were reviewed. CONTINUED ON 809-C Three staff interviews corroborate that at the same time as the incident, there was a care staff Christmas party on 12/17/25 happening around 12:30PM in which there should have been some care staff supervised the floor. The administrator nor S2 were present during this incident. S3 stated they were at the facility but did not assist with this incident. S4 reported that R1 stated "someone pushed me". The Medication Technician was called by S4 and R1 was transported to the hospital. Three staff reported R1 often knocks on other resident doors thinking it was their room. R2's care plan stated supervision and re-direction shall be implemented. On 12/29/25, S3 stated R1 was being evaluated by their physician for medication adjustment due to their diagnosis and behaviors. LPA went on a facility tour with S3 at around 2:00 PM. LPA observed there were ceiling panels pieces that were damaged from the roof leaks, there is water dripping from three new missing panels/panel pieces on the second floor hallway, in which there are trash bins placed below to catch the water. S2 stated no residents have fallen due to wet floor and maintenance is periodically checking for new leaks and ensuring there is no fall hazards. LPA is requested for facility to have the building evaluated to ensure it is safe and habitable for residents. At this time, the roofing is not able to be repaired until spring of 2026 and it is uncertain if residents are being exposed to mold and asbestos particles as a result to the ongoing water damage. LPA observed some trash bins have accumulated over a gallons worth of water. LPA provided guidance around ensuring preventative measures are being taken, including cleaning up water leaking onto the floor and bins catching water leaks are being emptied out at least twice per day. LPA requested delayed egress fire clearance verification, to be submitted to licensing by 1/2/25. There is one deficiency cited during this case management visit. An exit interview was conducted with the Licensee, and a copy of these LIC 809 reports were provided to the facility.the state’s words, verbatim · CDSS document, Dec 29, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jan 5, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall ... (2) ... be accorded safe, healthful and comfortable accommodations ... This requirement was not met as evidenced by record review and interviews in which it was learned that dementia resident, R1, has often tried to enter other resident rooms. On 12/17/2025, resident 2, R2, pushed R1 when they attempted to go into R2's room. Per staff interviews, R1 has been in the hospital for 10 days and has a bone fracture. This poses an immediate/potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 29, 2025

Plan of correction: By POC due date, facility staff will submit a plan to ensure there is adequate care and supervison for all resdients in addtion to a plan to ensure preventative measures are being taken for individuals with dementia including having an updated physician evaluations and reappraisals are done each time there is a change in baseline for any resident. Moreover, facility staff will ensure all staff have the required dementia , care and supervision, and reporting requirments, trainings.

Type of visit: Case Management - Other

On 12/18/2025, Licensing Program Analysts (LPAs) Cynthia Tamayo and Avelina Martinez made an unannounced case management visit to this facility to conduct a case management visit. LPAs met with Susan McClure (S2), Dietary Manager and assistant administrator and explained the purpose of today's visit. Administrator, Sherry Richardson (S1), was not present during this visit. LPAs discussed the plan of correction deficiencies cited 11/14-19/25 and requested an update on the following : 1. Maintenance and Operation 87303 (a): The building roof and resident exterior patio were not in good repair. The exterior resident back courtyard patio is under construction and closed to residents in care. Residents use the covered side patio area at this time. Plan update: Code enforcement documentation shows that the facility was found to be in violation of code enforcement on 8/6/24, in which repairs were initiated by the facility. Code enforcement came back out to the facility on 10/15/24, in which they deemed the repair work was not done correctly by the contractor that was hired; the facility initiated a new contractor to complete the violation corrections and is in process to be completed this month. The construction crew received approval to pour the cement the week of 12/8/25 and it has been curing in the patio area. LPAs observed construction workers working on the patio area during this visit. Sacramento county inspector is coming out tomorrow, 12/18/25. S2 will send Sacramento County inspector’s contact information to LPAs. Sacramento code enforcement confirmed that the facility obtained a permit earlier this year. S2 stated code enforcement has not been back out in 2025 and the reason for delay is due to clarification and communication, as staff were not able to get a hold of permits and planning department. CONTINUED ON 809-C 2. On 11/19/25, LPA Martinez observed there was mold and leaks in two vacant resident bedrooms on the second floor. Remediation quotes from a third party company confirmed 6 out of 6 bedrooms tested positive for mold and asbestos. LPAs spoke with S2 via phone call during this visit in which they stated they will put a plan in place to test additional rooms throughout the facility for asbestos and mold as well. LPAs informed staff that the entire facility including all resident rooms, common areas, and exteriors and facility staff must be safe for residents and staff. Administrator will also ensure precautions will be put in place to ensure safe remediation is completed. Roof: Due to mold and asbestos needing to be addressed first in addition to rainy conditions, the roofing repairs are not able to start until Spring 2026. Documentation of quote from one roofing company states “this application can only be done between April and September with adequate outside temperatures per manufactures instructions”. During a facility tour with S2, LPAs observed there was water damage such as warping, bubbling, and discoloration on several hallway ceiling panels on the both floors of the facility. LPA also observed there was water leaking from a ceiling panel on the second floor near in room 219 and 220, in which trash bin was placed underneath the hole in the ceiling hole to collect the water dripping from the ceiling panel. 3. Fire Safety 87203: The facility's last fire alarm system inspection was completed on April 11, 2025. The last fire testing and maintenance inspection was on May 20, 2025. Sprinkler system and water gong were not in good repair which. S2 stated the facilities sprinkler system plan, and water gong repairs plan update: Fire Marshall, came to the facility on 11/18/25 and the documentation was received during this visit. Sprinklers were added, gongs were repaired, and fire alarms pull boxes were inspected. POC was cleared. 4. HSC 1569.695(c): quarterly fire drills were not being completed by facility staff POC cleared. LPA observed the light fixture in the fire exit stairwell was non- operational during this visit. S2 had maintenance replace the light bulb of the stairwell during this visit. 5. Incidental and Medical 87465(a)(6) (6) facility did not maintain an accurate record of dosages of medications. POC cleared and staff agrees to continue maintain accurate MAR. CONTINUED ON 809-C 6. General Food Service Requirements 87555(b)(17): Per food service consultation report, the last food service consultation was in December of 2019. Additionally, there is not a nutritionist, dietitian, or home economist available at the facility. Plan update: Qualified Nutritionist, Dietitian, or a Home Economist is scheduled to conduct audits in January 2025, and facility will submit findings to Licensing upon completion. 7. Incidental Medical and Dental Care: 87465(h)(4): Due to the alteration of a residents \ medication bottle label. Plan update: POC cleared, and facility agrees to not make any alteration of a residents medication bottle labels. 8. 87411(c)(1) Personnel Requirements – [ [2] out of [8] staff did not have a current first aid certificate Plan update: POC was cleared and facility staff will ensure staff have a current first aid certificate. 9.P&I financial ledgers. Current surety bond amount is $5,000 via CAN Surety. Business office manager, Rabinder Singh (S3) stated residents PNI is deposited into a facility bank account designated for residents' money and all payees have designated payees. S3 stated Facility will Bank information to LPA by 12/22/25. Facility staff will review 87217 Safeguards for Resident Cash, Personal Property, and Valuables. 10. Facility sketch that includes camera locations will be submitted by 12/22/2025 11. Administrator oversight: Per LIC 500, Administer Sherry Richardson is scheduled at this facility 4 days per week from 7:00-17:00 however their schedule is variable and the LIC 500 is not accurate at this time. S1 holds current certificate #7007545740 that is valid thru 01/25/2027. S2 hold administrator certificate #7007207740 which expires12/28/2026. S1 stated they are spending most of their time overseeing Country Place Assisted Living – 075601547 in Antioch and S2 is "like the main administrator" for the most part. S2 stated the licensee/owner of the building has been informed of the conditions of the building. S3 assists with administrator duties. Med techs act as leads in case of an emergency. An updated LIC 500 and LIC 308 will be submitted to LPA by 12/22/25. S1 stated maintenance workers are scheduled to be present at the facility next week. LPAs discussed the importance that a qualified administrator is present next week to ensure there is oversight over the roof leaking issues during the upcoming rainy days. 12. LPAs advised S2 on ensuring the elevator certificate is renewed expiration date: January 8th, 2026. CONTINUED on 809-C 13. Emergency Safety Plan: In the event residents need to be relocated, an updated safety plan shall be in place. Facility staff agree to submit written emergency/ safety plan update by 12/22/25. Licensee shall be included in the development of this plan. As a result of this visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with S2 and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Dec 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Dec 19, 2025

87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by the light fixture in the fire exit stairwell was not in good repair, which poses a health a health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: By POC due date, facility will submit verification fire exit stairwell light fixture is in good repair. LPA observed S2 request maintence person repair the light during this visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Dec 22, 2025

87405 Administrator - Qualifications and Duties (a) ...The administrator shall have sufficient freedom from other responsibilities ... on the premises a sufficient number of hours ... coverage by a designated substitute ... qualifications adequate to be responsible and accountable for management and administration. Based on observation, interview, and record review, the administrator did not ensure enough oversight to ensure the building's was kept safe and free from to hazardous materials which poses a potential health, safety rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: By POC due date, licensee(s) and administrator(s) will submit a plan to remediate mold, aspestos, and pending code enforcement violations as safely and efficiently as possible. Additionally, a written safety and relocation plan will be submitted in regards to the unresolved roofing leaks which may be impacted by upcoming rainy days. Facility shall also submit a update to Community Care Licensing on a weekly basis from 12/26/25 - 6/26/25.

Allegation investigated: Staff did not ensure resident's medication was provided.

On 11/26/25, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to conduct a follow-up investigation into an allegation noted above. LPA met with Susan McClure, Assistant Administrator (S2) and stated the purpose of this visit. Administrator, Sherry Richardson (S1) arrived later on during this visit. LPA requested the following records for review: • LIC 500 • LIC 9020 And the following records for R1-R4: • LIC 602 • Appraisal • Medication list • November SIRs and discharge documents •MARs Substantiated It was alleged that staff did not ensure resident's medication was provided, the investigation into the above allegation consisted of interviews and record reviews. LPA conducted an interview with staff S1-S3. Record review reveal that R3 is prescribed psychotropic medications due to their mental health; Invega Sistenna (234 mg/1.5 ml) is prescribed to be injected intramuscularly every 28 days. S3 stated there was a delay on the pharmacy delivering the medications to the facility. Daily notes indicate S3 contacted the pharmacy the week of 10/27 and 11/5/25 in regard to requesting the medication for R3 be delivered. S3 stated R3 was supposed to get the shot on 11/3/25, however they did not received the Invega shot until 11/7/25.S3 stated they forgot to log it on the Medication Administration Record (MAR) and there is no record that R3 received the injection in November 2025. Per S3, R3 has not missed the injection in the past, aside from the month of June where there was a delay in medication, in which R3 refused the injection on 6/16/25 and it was given on 6/17/25. Based on interviews and observations of the LPA and review of records the allegation, staff did not ensure resident's medication was provided, is substantiated. As a result, the allegations above are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted S1-S3 and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Nov 26, 2025 · control 27-AS-20251123203239

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 5, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility.... (4) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: Facility staff did not providescheduleded medication to resident 3 (R3) on 11/3/25. S3 stated medication was administered 11/7/25, however it was not recorded on the MAR. This poses an immediate/potential health risk to residents in care.the state’s words, verbatim · CDSS document, Nov 26, 2025

Plan of correction: By POC due date, licensee will submit of review and understating of Title 22 regulation: 87465 Incidental Medical and Dental Care in addition to providing quality assurance for MARs on a weekly basis.

Type of visit: Case Management - Deficiencies

On 11/26/2025, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to this facility to conduct a case management visit for deficiencies observed on 11/26/25. LPA met with Sherry Richard (S1) and Assistant Administrator Susan McClure, Administrator (S2) and stated the purpose of this visit. Upon record review of medications and Medication Administration Record (MAR) LPA observed, Resident 3 (R3) did not receive their scheduled in vega injection in November 2025 and licensing nor authorized person were notified. S3 stated medication was administered on 11/7/25, however it was not documented on the Medication administration Record (MAR). Licensing Regional Office nor R3s LPS conservator, were informed about the missed/delayed medication. S1-S3 stated they were unaware missed medications/refusals constitute special incident reporting. Guidance provided to S1-S3 regarding MARs and reporting requirements. LIC 9102s provided. No deficiencies were cited on this case management visit. An exit interview was conducted with Sherry Richardson and Susan McClure and a copy of these LIC 809 reports and LIC 9102s were left at the facility.the state’s words, verbatim · CDSS document, Nov 26, 2025

Type of visit: Required - 1 Year

On November 14, 2025, at 10:15 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Susan McClure and explained the purpose of today's visit. Administrator holds current certificate and expires in January 2026. The facility is licensed for 144 non-ambulatory residents. There are currently 84 residents who reside at this facility. The facility has an approved hospice waiver for ten. The facility's last fire alarm system inspection was completed on April 11, 2025. The last fire testing and and maintenance inspection was on May 20, 2025. Last fire inspection report indicates fire sprinklers are not in good repair and water gong is in operable. The last fire drill documentation states March 10, 2025. The facility shall conduct a drill at least quarterly for each shift. LPA Martinez reviewed the inspection control plan and disaster preparedness plan. LPA Martinez reviewed food service consultation report. The last food service consultation was in December of 2019, and LPA Martinez was informed by S1 there is not a nutritionist, dietitian, or home economist available at the facility. Continued... LPA Martinez reviewed two medication administration records (MARs). Resident 1 (R1) was not maintained. R1's MAR was not signed on November 5th and 8th. R1's vitamin B-12 MAR entry does not reflect medication order. MAR entry for B-12 states 500 MG; the Medication Bottle states 1,000 MG; The medication order states 1,000 MG. R1's Donepezil HCL bottle label order was altered with a black marker. The Donepezil bottle states 10 MG and medication order states 5 MG. Additionally, there is no Donepezil split order documentation. R1's Ferrous sulfate 325 MG Tablet MAR entry does not reflect the medication bottle order. LPA Martinez will return at a later date and time to complete 2025 annual inspection. The following deficiencies can be found on the D-Page: Fire Safety 87203, 1569.695 (c); Emergency Plans; and Incidental and Medical 87465(a)(6); Incidental and Medical 87465(h)(4). An exit interview was conducted and a copy of this 809 report, 809-D page, and appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Nov 14, 2025

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Kevin Gould and Cynthia Tamayo conducted an unannounced case management visit at facility on 4/9/25 to conclude the investigation of the Resident 1’s (R1) death that occurred on 1/4/2024. LPAs Tamayo and Gould met with facility staff, Rabindar Singh and Assistant Administrator, Susan McCloure and together discussed the investigation details. On 4/3/2025, the department obtained a copy of R1’s death certificate from the Sacramento County Office of Vital Records. R1’s date of death is listed as 1/4/2024, and the cause of death is hanging. There were no other significant conditions contributing to his death. Multiple staff denied R1’s made prior attempts to commit suicide, had any changes in behavior, or verbalized any comments to suggest that R1 was going to take their own life. Medication Technicians stated they administered R1‘s medications. R1’s medication records documented he was receiving his medication as prescribed. The Department investigations revealed multiple staff interacted with R1 earlier that day and did not notice any changes in his behavior or anything concerning before R1's death. Staff conducted client rounds every two hours and R1 did not require an additional level of supervision. Multiple staff reported it was not unusual for R1 to spend time outside during the day. Report Continued on LIC 809-C Based on the interviews conducted during the investigation process, records review, video footage, and statements obtained during the investigation process, the department did not observe any violations of Title 22 regulations. There are no deficiencies observed or cited during today's inspection. Exit interview was conducted with facility staff and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 9, 2025

Allegation investigated: Facility staff do not provide transportation for resident to their medical appointments. Facility staff do not provide meal to meet residents' dietery needs. Facility staff do not ensure that the facility is free of pests. Facility staff do not respond to resident calls in a timely manner. Illegal eviction.

On 2/27/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct a follow up complaint visit regarding the allegations noted above. LPA met with Susan McClure, Assistant Administrator (AAd) and stated the purpose of this visit. Throughout this investigation, this LPA conducted interviews of relevant persons, record reviews of relevant documents and facility observation. Allegation: facility staff do not provide transportation for resident to their medical appointments. The investigation into this allegation consisted of interviews and record reviews. The Resident Van Appointments log, covering the period from 12/12/2024, to 12/31/2024, indicates that transportation is offered to residents Monday through Friday. However, there are several limitations to this service, such as the restriction that no appointments are scheduled after 2:00 PM, and that only four appointments per day are available. Additionally, lab appointments can only be scheduled before 8:00 AM, and there are activity outings on Thursdays. {1 of 7} Unsubstantiated In the bathroom inside R1’s unit, several issues were identified. The bathtub exhibited what appeared to be a water stain or mildew, marked by a reddish-brown discoloration. Furthermore, the shower faucet was observed to be leaking, which prompted LPA to attempt to turn off the water. However, the faucet knobs were already turned to the "off" position, and water continued to leak . Additionally, the ceiling above the shower displayed a water stain visible through the paint. Further observations were made during an unrelated complaint visit on 12/12/2024. LPA, accompanied by Assistant Administrator Susan McClure (AAd), inspected multiple resident units. In resident unit #220, a resident reported a ceiling leak during a rainstorm. The leak was coming from the area near the sprinkler, which was located near the window. AAd took photos of the leak and confirmed that it was reported to maintenance. Similarly, in resident unit #120, LPA observed a sink that was leaking when the faucet was turned on. Despite previous attempts by maintenance staff to fix the issue, the sink continued to leak, with water dripping from the pipe under the sink into a basin. An interview with a witness (W1) on 1/29/2025, further substantiated the allegations of disrepair. W1 confirmed noticing mold in R1's bathroom during their visit and stated that an email had been sent to the facility manager requesting that the shower be scrubbed with an anti-mold solution. Based on these observations, combined with reports from residents, there is a preponderance of evidence to SUBSTANTIATE this allegation. 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 809-D per Title 22 Regulations, Division 6 and Health and Safety Codes. Exit interview was conducted and a copy of this report and appeal rights were provided. Allegation: facility staff do not provide transportation for resident to their medical appointments (con't). Interviews conducted on 12/31.2024 revealed that there may be communication challenges between the staff and R1 regarding transportation needs. Staff interview stated that R1 has not consistently provided staff with adequate information about appointment dates, and there have been instances where R1 refused to go to scheduled appointments. This lack of communication could be contributing to difficulties in arranging transportation. Further review of R1's care notes revealed that on 12/5/2024, R1 initially refused to go with the driver for a scheduled appointment, only to later inform the driver that R1 was ready to go. On 12/3/2024, R1 notified staff about an upcoming appointment on 12/11/2024, but was informed that the driver would not be available on that date. R1 expressed that it was the driver’s responsibility to resolve this issue, indicating some frustration with the transportation arrangement. While these records suggest occasional communication challenges and instances where R1 refused or delayed transportation, there is no preponderance of evidence to substantiate the claim that staff are not providing transportation for R1's medical appointments. Therefore, this allegation was UNSUBSTANTIATED. ********************************************************************************************************************************** Allegation: Facility staff do not ensure that facility is free of pest. The investigation into the allegation that facility staff do not ensure that facility is free of pest consisted of interviews and record reviews. Based on a review of various records and interviews conducted with staff, there are mixed findings regarding the effectiveness of pest control measures at the facility. According to the contract with Clark Pest Control, the technician is required to inspect both the interior and exterior of the facility twice monthly, addressing any pest activity and providing inspection reports after each service. The service scope includes addressing insect issues such as roaches and bed bugs, as well as preventive measures for rodents. Extra services are also available upon request. {2 of 7} Allegation: Facility staff do not ensure that facility is free of pest (con't). The reviewed records from Clark Pest Control's service reports between 6/24/2024 and 12/26/2024, confirm that the facility has received pest control services at least twice a month. During these visits, technicians addressed primarily insect issues and took preventive measures for rodents. For example, on 12/26/2024, the technician inspected both the interior and exterior of the facility, replaced non-toxic monitors, and reported minimal insect activity. The technician also treated the kitchen and baited the hallway to control cockroaches. However, it was noted that a service attempt in room #120, occupied by Resident_1 (R1), was refused by the R1, who did not want chemicals used in the room. This refusal was recorded in both the service report and the pest sighting log, which also noted a cockroach sighting in R1’s room on 12/26/2024. The Pest Sighting Log from 8/17/2023 to 12/26/2024, tracks sightings of pests reported by staff and/or residents. The log shows that sightings of cockroaches in R1’s room were logged, with the technician addressing these sightings on 12/26/2024, despite R1’s refusal of service. According to the log, no further actions were taken to address the pests in R1’s room after the refusal. An interview with Staff_1 (S1) revealed that S1 accompanied the Clark Pest Control technician to R1’s room on 12/26/2024. S1 confirmed that R1 refused the service, citing concerns about chemicals in the room. S1 further stated that no additional attempts had been made to address the cockroach issue in R1’s room following the refusal. The records and interviews suggest that the facility is generally proactive in addressing pest control, with services provided regularly by Clark Pest Control. It is unclear whether further steps are being taken to respect the resident's preferences while also ensuring the facility remains pest-free. This could potentially impact the overall effectiveness of pest control measures at the facility. Based on the information gathered, this allegation was UNSUBSTANTIATED. ********************************************************************************************************************************** Allegation: Illegal Eviction. The investigation into this allegation consisted of interviews and record reviews. On 1/29/2025, LPA conducted interviews regarding an alleged illegal eviction of (R1) from the current facility. {3 of 7} Allegation: Illegal Eviction (con't). According to Witness_1 (W1), R1 was served an eviction notice by the facility on 1/17/2025, which gave R1 until 2/16/2025, to vacate the premises. W1 expressed concerns about the difficulty of finding an alternative placement for R1, as this facility was the only one willing to admit R1. W1 added that R1 was willing to move to either Sacramento or Contra Costa County and that R1 was actively trying to help find another placement. However, W1 acknowledged that R1 could be "colorful" in R1’s communication, making the process more complicated. W1 further noted that R1 had financial difficulties from the start, which contributed to the eviction, as R1 had not paid rent since R1’s admission in October 2024. Despite attempts by W1 to reach R1's social worker, no response was received. In a separate interview, R1 confirmed that R1 received the eviction notice hand-delivered by facility staff Sherry Richardson and Susan McClure. R1 disclosed that R1 had attempted to make payments on 12/27/2024, and 1/6/2025, but was informed that the business manager, following instructions from the administrator, would not accept the payments. R1 was unsure why payments were denied and could not provide evidence of the checks R1 attempted to submit. Interview with business manager confirmed that the refusal to accept payment was due to a verbal notice of eviction from the meeting held in December 2024. Susan McClure, the Assistant Administrator, provided additional context regarding the eviction during an interview on 12/31/2024. She explained that the eviction was being pursued due to R1's failure to pay rent and R1’s problematic behaviors, including refusing care, medication, and food. McClure noted an incident where R1 allegedly attempted to strike staff with a grabber, though no injuries occurred. Furthermore, Susan indicated that R1 had made inappropriate accusations towards male staff members when they entered R1’s room. A record review of the eviction notice revealed that it was based on R1's arrears of $6,080.28, with no rent payments made since R1’s admission. The notice was hand-delivered to R1 by Richardson and McClure and also emailed to W1. The eviction notice was accompanied by an invoice detailing the outstanding rent amount. {4 of 7} Allegation: Illegal eviction (con't). Additionally, a meeting held on 12/5/2024, between facility staff, W1, and R1 revealed that R1 was dissatisfied with R1’s living situation and that nonpayment of rent was a key factor in the decision to evict R1. During the meeting, R1 was offered a payment plan but expressed frustration with the facility, alleging that external forces were conspiring against R1. It was also noted that R1's money had been spent on personal purchases, such as Amazon orders. Based on the gathered information, the facility's actions appear to be within the bounds of the eviction process, as they followed protocol for notifying both R1 and R1’s social worker. Based on the gathered information, this allegation was UNSUBSTANTIATED. ********************************************************************************************************************************** Allegation: Facility staff do not provide meal to meet residents' dietary needs. The investigation into this allegation consisted of interviews and record reviews. On 12/31/2024, an interview was conducted with Assistant Administrator Susan regarding the allegation that facility staff do not provide meals to meet residents' dietary needs. Susan explained that staff are aware of residents' dietary restrictions and preferences, maintaining a list to ensure proper food delivery. She emphasized that they always follow these dietary guidelines and that they have a binder that staff use for reference and training. Susan also noted that some residents, like R1, may refuse the food provided, but this does not indicate a failure to meet their dietary needs. On 1/29/2025, LPA Arvin Villanueva conducted an interview with R1 concerning food service. R1 confirmed that food trays are brought to her daily. According to a review of R1’s food preferences on file, R1 primarily eats vegetables, refrains from eating most meats, but consumes chicken, turkey, and eggs. Additionally, R1 enjoys drinking wine. There is no indication in the records that R1 requires a special diet. Further review of R1’s care notes revealed that R1 often refuses the food tray delivered to R1’s room and does not eat in the dining room. These notes, however, did not suggest any failure on the part of staff in meeting R1’s dietary needs, as no special diet was prescribed. Additionally, R1’s care plan, dated 9/20/2024, and ALWP assessment, dated 6/4/2024, both confirmed that R1 does not require any special dietary accommodations. Based on this information, there is no preponderance of evidence to suggest that the facility staff do not meet R1’s dietary needs, therefore, this allegation is UNSUBSTANTIATED. {5 of 7} Allegation: Facility staff do not respond to resident calls in a timely manner. The investigation into this allegation consisted of interviews, observation, and record reviews. The assistant administrator, Susan, in an interview conducted on 12/31/2024, indicated that staff generally respond to calls in a timely manner. However, she explained that R1’s selective preferences for certain staff, who are not always on schedule, may contribute to delays in care. Susan noted that R1 only allows a few specific staff members to assist R1, which can affect response times when those staff members are unavailable. Additionally, at times, R1 would not let staff turn off R1’s pendant until they are finished helping R1. Further interviews with staff members provided additional context. Staff member (S2) indicated that R1 has been difficult, citing instances where R1 screamed at staff or accused them of stealing R1’s mail. S2 suggested that R1 tends to call during busy periods, when care staff are attending to other residents, and that R1 doesn't always call when staff have time available. In contrast, S3 highlighted that, while the assigned caregiver may be busy, other staff members usually respond to R1’s call. S3 mentioned that R1 often leaves R1’s pendant on until staff completes the task with R!, and noted that the ideal response time for calls is within 10 minutes, although this may vary if staff are busy with other residents. S4 described the process of responding to pendant calls, where staff are expected to arrive within 2-3 minutes. However, S4 mentioned that R1 often does not turn off R1’s pendant until the staff has fully completed the task R1 requested, which could contribute to longer pendant light durations. Record reviews from R1's care notes also reveal a pattern of complaints regarding unresponsiveness to calls. For example, on 10/13/2024, R1 complained of not being helped when pressing the call light, although caregivers stated they had responded. On 10/25/2024, R1 accused the front desk staff of ignoring her calls, which was explained by the fact that the front desk staff were busy with other duties. Similarly, on 12/3/2024, R1 expressed frustration when a preferred caregiver was unavailable, and only caregivers R1 did not like responded. R1 has also been noted to scream when there is a delay in response time, even if it is only 2-3 minutes. {6 of 7} Allegation: Facility staff do not respond to resident calls in a timely manner (con't). A review of the call light/pendant response data further illustrates significant variability in response times, ranging from as little as 6 seconds to as long as 1 hour and 27 minutes. Staff interviews corroborated that R1’s refusal to turn off the pendant light until staff have finished their tasks with R1 may account for this wide range in response time. On January 29, 2025, during a complaint follow-up visit, the LPA conducted a test to measure the response time to R1's pendant call. Using a timer, the LPA noted that it took 19 minutes and 23 seconds for staff to respond to R1’s call, which was recorded after R1 pressed the pendant button. Staff member explained that she had just arrived at work when responding to the call. In conclusion, the allegation that facility staff do not respond to resident calls in a timely manner appears to be UNSUBSTANTIATED by the data and interviews. However, factors such as R1’s selective preferences for caregivers and R1’s tendency to leave the pendant on until tasks are fully completed contribute to the extended response times. A finding of unsubstantiated means that although the allegation may have happened the preponderance of evidence does not prove it. No deficiencies were cited as a result of this visit. An exit interview was conducted and a copy of this report was provided. {7 of 7}the state’s words, verbatim · CDSS document, Feb 27, 2025 · control 27-AS-20241223152310

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 6, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. The above requirement is not met as evidence by observation and interviews. R1's sink and shower faucets were leaking. Additionally, a resident reported their ceiling to be leaking during LPA's visit. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 27, 2025

Plan of correction: Per discussion, Licensee is currently making necessary repairs to ensure complaince with the cited regulation. Licensee agreed to submit a statement of understanding of the cited regulation pertaining to maintenance and operation. Written statement to be submitted to the Department by POC due date.

Allegation investigated: Facility staff made sexual advances to resident in care.

On 2/27/25, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to conduct a follow-up investigation into an allegation noted above. LPA met with Susan McClure, Assistant Administrator (AAd) and stated the purpose of this visit. The investigation into the above allegation consisted of interviews and record reviews. Through interview with Resident_1 (R1), who reported incidents occurring on the weekend of January 26-28, 2025. The complaint indicated that sexual advances took place on Friday, Saturday, and Sunday, though during subsequent interviews, it was clarified that only Saturday and Sunday were mentioned in the initial email from R1. {1 of 2} Unsubstantiated Interviews revealed that R1 described multiple allegations, including incidents involving a male staff member entering R1’s room unannounced. However, R1 did not report any claims of sexual advances or inappropriate touching by the staff member, as initially alleged. Interviews conducted with R1 indicated that R1 denied any accusations of sexual assault, providing no further evidence to substantiate these claims. Additionally, through interview, R1 mentioned that a female caregiver was present during the alleged incidents, which may further contradict the notion of inappropriate behavior occurring in isolation. Further interviews into the staffing schedule revealed that the accused male staff member did not work on Friday or Saturday, according to information provided by staff member Susan McClure. Given the lack of corroborating evidence, the inconsistency in the timeline of the alleged incidents, and the confirmation of staff schedules, there is no preponderance of evidence to substantiate the allegation of sexual advances by the accused staff member. Therefore, the allegation was found to be UNSUBSTANTIATED. Exit interview was conducted with Susan McClure and a copy of this report was provided. {2 of 2}the state’s words, verbatim · CDSS document, Feb 27, 2025 · control 27-AS-20250127144608

Allegation investigated: Staff are not preventing resident from harassing other residents in care.

On 2/6/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct a follow up complaint visit regarding the allegation noted above. LPA met with Susan McClure, Assistant Administrator, and stated the purpose of this visit. The investigation into the above allegation consisted of interviews and record reviews. A review of Resident1’s (R1) documents indicated several instances of agitation and confusion, consistent with their diagnosis (D1) dementia and Alzheimer’s. These behaviors included occasional aggressive actions, such as trying to hit other residents, shouting, and entering other residents' rooms mistakenly. However, there was no consistent evidence that R1 intentionally harassed other residents or that the staff failed to intervene appropriately. {1 of 2} Unsubstantiated Interviews with care staff (S1 – S6), including those who have worked closely with R1, consistently described R1 as a kind person who does not have malicious intent towards others. Staff members reported that R1’s actions were largely a result of their cognitive impairments and confusion, which led R1 to occasionally enter other residents' rooms by mistake or engage in disruptive behaviors, like shouting. R1’s inability to remember basic facts and their tendency to wander were contributing factors to their confusion. Additionally, interviews did not indicate that R1 had physically harmed or verbally abused other residents with intent. Interviews also revealed that R1 had a history of confusion with room locations, particularly with a Resident2 (R2), who had previously complained about R1 entering their room. However, R2 had relocated to another part of the facility, and since that move, there had been no further complaints. Also staff had stated that they actively worked to manage R1’s behaviors by providing constant supervision and assistance with activities of daily living (ADLs), including showering, meals, and ensuring R1’s safety while wandering the facility. Although R1’s behaviors were occasionally disruptive, there was no evidence that staff ignored or failed to address these issues. Staff were aware of R1’s condition and took measures to offer R2 another location to move to within the facility. Based on the information gathered, the allegation that staff are not preventing R1 from harassing other residents in care was found to be UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened the preponderance of evidence does not prove it. Exit interview was conducted with Susan McClure and a copy of this report and appeal rights were provided. {2 of 2}the state’s words, verbatim · CDSS document, Feb 6, 2025 · control 27-AS-20241017115504

Allegation investigated: Facility installed a surveillance device in a resident's room without consent.

On 12/31/2024, at 2pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility to conduct a follow up complaint visit regarding the allegation noted above. LPA met with Susan McClure and stated the purpose of this visit. The investigation included interviews with relevant parties, observation of the facility, including resident rooms and common areas, and a review of pertinent records, such as resident admission agreement and care notes. Interview with an outside agency reported inspecting R1’s room and found no evidence of surveillance devices. Interview with facility staff revelaed that surveillance cameras were installed only in common areas for monitoring purposes and that no cameras were placed in resident rooms. From the interviews with residents, one resident suspected that the smoke detector in their room contain a hidden camera. R1 informed LPA that they were becoming suspicious after returning from a trip and pointed to the device installed at the ceiling, which had been partially wrapped in paper, as evidence of hidden camera. {1 of 2} Unfounded LPA and facility staff conducted facility observation which include inspections of 11 resident units. Of all the resident units were inspected, LPA did not find any clear evidence of surveillance devices, including cameras. Devices that were observed installed at the ceilings of resident units were identified as smoke detectors and sprinkler systems. However, the only visible surveillance cameras that were observed were in common areas, including hallways and dining rooms, but not in private units or bathrooms. Record review of Admission Agreement explicitly states that no surveillance devices are installed in private rooms. The agreement also specifies that residents would be notified prior to the implementation of such devices in private areas. Based on interviews, facility observations, and document reviews, the allegation that Skypark Manor staff installed a surveillance device in resident's room without consent is UNFOUNDED. The devices in question were identified as standard safety equipment, and no evidence was found to support the claim. Note that a finding that is unfounded means that the allegation is false, could not have happened, or is without a reasonable basis. No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 31, 2024 · control 27-AS-20241209094904

Type of visit: Case Management - Incident

On 12/12/2024, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to this facility to conduct a case management visit regarding a death incident. LPA met with the Assistant Administrator Susan McClure and stated the purpose of this visit. The Regional Office (RO) received a death report for resident (R1), who was reported to have passed away on 10/15/2024. Facility staff (S1) reported that R1 was found unresponsive on the floor of their room with no pulse. CPR was provided until paramedics arrived and continued CPR until R1 was pronounced dead at 8:42 AM. Prior to being found on the floor, R1 had been sitting in their chair. An investigation was conducted by the Department, focusing on the review of the death certificate. The death certificate listed cardiac arrest as the immediate cause of death, with the following contributing health conditions: C1 and C2. It was noted that no autopsy or biopsy was performed. The investigation concluded that there were no signs or indicators suggesting that R1's death was questionable. Per the California Code of Regulations, Title 22, no deficiencies were cited during this visit. An exit interview was held with Susan McClure, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 12, 2024

Type of visit: Required - 1 Year

On 10/23/24, at 10:15am, Licensing Program Analyst (LPA) Arvin Villanueva, arrived to this facility unannounced to conduct their required annual inspection visit. LPA met with Susan McClure, Assistant Administrator (AD), and explained the purpose of the visit. The facility currently has an approval to retain/accept 144 non-ambulatory residents, 10 of which may be bedridden residents. LPA and AD toured the facility to ensure compliance of Title 22 regulation. Facility is a two-story building located in a residential neighborhood. LPA observed the first floor, second floor, the activity room, dining room, elevator, stairwells and random resident apartments/units. Facility has a 144-resident capacity for both assisted living and memory care residents. Memory care area is located on the first floor. Facility has one elevator and currently operable and in good repair during this visit. Facility has 3 stairwells. Each stairwell were equipped with evacuation sling located in the second floor for emergency use. 1 of 3 stairwell is equipped with evacuation chair located at the first floor of the stairwell. LPA observed 5 of 6 fire extinguishers to be expired and were last serviced on 10/4/23. The resident apartments/units are spacious enough to accommodate the residents' furnishings. 6 of 6 resident apartments/units were observed. Each resident apartment/unit is equipped with resident bathroom, small refrigerator, and air conditioning/heating unit. The air conditioning/heating unit are operated by the residents. Each apartment/unit is equipped with sprinkler system. 6 of 6 resident bathrooms were observed. Water temperature in 6 randomly selected bathrooms (in a resident apartment/units) were measured at between 110 and 114 degrees F. In one resident bathroom (R1), their hot water sink faucet did not have hot water. In one resident bathroom, it did not have a grab bar by the toilet for non-ambulatory resident. Technical Advisory (TA) was provided to AD to clean out cobwebs observed at the ceiling in resident apartment/units. TA was also provided for facility to conduct minor repairs such as drawer in disrepair observed in one resident apartment/unit and medicine cabinet in disrepair in another resident apartment/unit. Photos were taken for reference. {1 of 2} LPA observed a shaded area in the courtyard with tables and chairs. Additionally the outdoor area for activities is secure for dementia residents. Outdoor passageways, walkways, driveways, and steps are free from obstructions and hazards. The facility does not have bodies of water at this time. LPA and AD inspected the kitchen and main dining area. Kitchen was observed to be clean and sanitized. Food were observed to be properly stored during this visit. Facility kitchen has 5 freezers, 2 refrigerators and 2 pantries for dry and canned foods. Main dining room was observed to be clean and sanitized. This is also where the fireplace is located and it was observed to be enclosed. The medication room is located in the first floor and medications were observed to be properly stored, locked and inaccessible to residents in care. LPA conducted file review of 6 resident files and 8 staff files. LPA was unable to review facility's infection control plan and Emergency Procedure Plan at this time. Per interview with the Business Office Manager, they have not conducted quarterly drills since COVID. The following deficiency was observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Failure to correct the deficiency may result in civil penalties. An exit interview was conducted with AD, and a copy of this report and appeal rights were provided. {2 of 2}the state’s words, verbatim · CDSS document, Oct 23, 2024

The state marks this report as 9 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

On 3/14/24, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced case management visit to follow up on the death report of a resident. LPA met with Medication Technician Erisa Jonathan and explained the purpose of today’s visit. The purpose of this case management visit is to follow up on a death report the Department received on 3/8/2024. According to the report, caregiver discovered resident (R1) was on the floor when doing rounds at 6:14am on 3/5/2024. Resident reported to staff that they were having difficulty breathing. 9-1-1 was called and upon their arrival resident has stopped responding. Paramedics performed CPR but when resident didn't respond they pronounced resident dead at 7:14am. LPA Truong conducted file review for former resident and obtained resident’s pertinent documents. LPA could not interview staff who first discovered R1 as they were not present at the time of visit. Facility administrator and assistant administrator have left for the day; therefore, no additional information was gathered. Per the California Code of Regulations, Title 22, no deficiencies were cited during this visit. LPA will return at a later date to complete the investigation. Exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 14, 2024

Type of visit: Case Management - Other

On 1/9/24 at 11:00am Licensing Program Analyst (LPA) Tung Truong conducted an unannounced case management inspection to ensure the health and safety of residents and address additional questions regarding the death of R1. LPA met with Assistant Administrator Susan McClure and explained the purpose of today’s visit. The death report indicated that, on 1/4/2024, resident (R1) was discovered behind the facility building hanging from a tree at approximately 3:50pm. A camera footage revealed that R1 secured a rope over a tree branch, climbed up on his walker and then pushed it way and hung himself. LPA Truong conducted file review for former resident and conducted interviews with staff members to get additional information regarding the former resident and to obtain additional information leading up to his death and the actions of the facility immediately after resident was found unresponsive. LPA could not interview staff who first discovered R1 as she is not present at the time of inspection. Based on the interviews, information gathered, and documentation reviewed there were no deficiencies assessed at the time of inspection. Exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jan 9, 2024

Allegation investigated: Facility has an infestation of rodents Facility is unclean

Licensing Program Analyst (LPA) Tung Truong conducted an unannounced complaint visit on 1/4/2024 at 1:00 pm to investigate the allegations listed above. LPA met with Assistant Administrator, Susan McClure and explained the purpose of today's visit. During today’s visit, LPA toured the facility and conducted interviews. Based on observations, interviews, and records review, it was determined that the facility has an infestation of rodents. LPA observed there were rat feces in rooms #136, 145 and 146. In addition, LPA observed the carpet is dirty and there were debris and rat feces on the floor in multiple rooms. As a result of the investigation, the preponderance of evidence standards has been met, therefore, the above allegation(s) is/are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D during this visit. Exit interview held, Appeal Rights discussed, copy of report given. Substantiatedthe state’s words, verbatim · CDSS document, Jan 4, 2024 · control 27-AS-20231228130547

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Jan 18, 2024

87307(d)(2) Personal Accommodations and Services: The following space and safety provisions shall apply to all facilities: The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met by: Based on interviews, observation, and file reviews, the licensee did not ensure the facility was clean/sanitary and healthful environment. The facility has a rodent infestation throughout the facility. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 4, 2024

Plan of correction: The facility has a contract with Clark Pest Control Company to conduct a bi-weekly pest treatments. Administrator agrees to conduct training on reporting pest/bug/rodent infestations by POC Date 01/18/2024. Administrator will email training materials by 01/18/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jan 18, 2024

87303(a) Maintenance and Operation...The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met by: Based on interviews and observation, the licensee did not ensure the facility is clean, safe, sanitary and in good repair at all times. There were rat feces and debris found in resident room #145. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 4, 2024

Plan of correction: The facility administrator agrees to conduct a maintenance and operation training for staff by POC day 01/18/2024. Administrator will email training materials by 01/18/2024.

Type of visit: Required - 1 Year

This is an initial Required -1 Year visit. Due to technical difficulties the type of visit 'Case Management - Annual Continuation' was selected because a ‘Required - 1 Year’ option was not available. The inspection Care Tool was also unavailable during today’s inspection. On 11/3/23, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a Required – 1 Year annual inspection visit. LPA met with Administrator Sherry Richardson and explained the purpose of the visit. Administrator holds certification # 6024408740 and expires on 1/25/2025. The facility is licensed for 144 non-ambulatory, of which 10 may be bedridden. Approved hospice waiver for 10. There are 84 residents in care currently. LPA toured and inspected the physical plant with Assistant Administrator Susan McClure. LPA observed the lounge area, lobby, and common areas. In addition, the kitchen areas, dining area, and activity room was toured. Medication room was toured. Kitchen was toured for adequate food supplies and storage. A review of the facility perimeter fence, side gates, and exits was conducted. A review of the resident rooms was conducted. LPA observed the facility to be clean and in good repair. LPA observed required furniture and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. Report continued on 809-C The hot water temperature was measured at approximately 115.5 degrees Fahrenheit in rooms #136, 135, 120, 228, and 215. The temperature inside the facility measured at 72.0 degrees Fahrenheit. LPA observed centrally stored medications, toxins, and sharp knives kept locked and inaccessible to residents. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. Proof of current liability insurance was observed. LPA requested resident and staff files for review. LPA reviewed six (8) resident files and six (6) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews. The following documents were obtained during today's visit: LIC 308 Designation of Administrative Responsibility, Administrator Certificate, and Proof of Current Liability Insurance, LIC 500 Personnel Report and LIC 610 Emergency Disaster Plan. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 3, 2023